Internet Mental Health

SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)






Internet Mental Health Quality of Life Scale (Client Version)

Internet Mental Health Quality of Life Scale (Therapist Version)

Big 5 Factors Of Mental Illness And Code For This Disorder
(The "6th Big Factor" of Mental Health, "Physical Health", Is Coded Normal or Green)

  • Avoidance of social situations because of a phobic fear of embarrassment or fear of being rejected by others.

  • Lasted for at least 6 months.

  • Social phobic situations are actively avoided or endured with intense anxiety or fear.

  • Social phobia causes significant impairment or distress.

  • Not due to a medical or substance use disorder.

Prediction

    Onset usually occurs in childhood or adolescence, but may occur in adulthood following severe embarrassment (e.g., due to tremor, incontinence, or memory loss caused by medical condition). Within one year usually 30% recover, and within a few years 50% recover.

Problems

Occupational-Economic Problems:

  • Significant impairment in academic, occupational and/or social functioning.

  • Underachievement or dropping out at school or work because of fear of public speaking, test taking, or authority figures.

  • Elevated rates of school dropout.

  • Decreased employment, workplace productivity, socioeconomic status, well-being, quality of life, and leisure activities.

  • Only about half ever seek treatment, and usually only after 15-20 years of experiencing symptoms.

Detached (Detachment):

  • Often have few friends.

  • Elevated rates of being single, unmarried, or divorced and with not having children.

Negative Emotions (Negative Emotion):

  • Has unreasonable fear of embarrassment or social anxiety

  • Exposure to the feared social situation always provoked strong anxiety

  • Recognized that this fear of embarrassment or social anxiety was excessive or unreasonable

  • Feared social situations were avoided or endured with intense anxiety

  • Fear of embarrassment or social anxiety occurred in most social situations

  • Fear of embarrassment or social anxiety caused clinically significant disability or distress


Fear, Generalized Anxiety, Phobia, Panic, Obsession, and Compulsion

Fearful avoidance is part of our instinctual "flight" response to adversity.

Our ancestors learned to fear dangerous things (e.g., snakes), and this harm avoidance saved their lives.

However, fear can spiral out of control. For example, an individual can develop a phobia to snakes in which the fear becomes excessive. The individual may then panic if exposed to snakes. This phobia can develop into an obsession in which the individual spends much of the time thinking about snakes, and how to avoid them. The obsession can develop into a compulsion in which the individual spends much of the time doing superstitious, compulsive, ritual behaviors aimed at avoiding snakes.

There are stages in the escalation of fear:

  • Normal Fear:
    Fear is normal if it is in proportion to the actual danger posed by the specific object or situation, and this fear doesn't cause significant distress or disability.

  • Generalized Anxiety:
    Fear can become excessive, and generalized with excessive anxiety and worry about a number of objects or situations. This anxiety is often associated with avoidance of the feared objects or situations and irritability. The anxiety in social anxiety disorder focuses on the generalized fear of negative social evaluation.

  • Phobia:
    Fear can become excessive, and specifically attached to specific objects or situations (e.g., fear of snakes). This phobic fear is out of proportion to the actual danger posed by these feared objects or situations, and the individual desperately tries to avoid whatever triggers the phobia. This phobic fear causes significant distress or disability. In social anxiety disorder, the individual develops a social phobia about being embarrassed, humiliated, or rejected in a social situation. Thus the individual actively avoids all social situations which run the risk of such negative evaluation.

  • Panic:
    Phobic individuals can develop a full-blown panic attack if exposed to whatever triggers their phobia. Individuals with social anxiety disorder may have panic attacks triggered by fear of negative evaluation.

  • Obsession:
    If the individual develops persistent, unwanted thoughts about the phobia; this is defined as an obsession. An obsession is an unwanted, recurrent, persistent, fear-provoking intrusive thought. Individuals with social anxiety disorder usually don't develop obsessions.

  • Compulsion:
    A compulsion is a ritual an individual develops to combat an obsession. Thus compulsions are fear-relieving avoidance behaviors. The individual feels driven to perform these compulsions. Individuals with social anxiety disorder usually don't develop compulsions.

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Click Here For Free Diagnosis

Limitations of Self-Diagnosis

Self-diagnosis of this disorder is often inaccurate. Accurate diagnosis of this disorder requires assessment by a qualified practitioner trained in psychiatric diagnosis and evidence-based treatment.

However, if no such professional is available, our free computerized diagnosis is usually accurate when completed by an informant who knows the patient well. Computerized diagnosis is less accurate when done by patients (because they often lack insight).

Example Of Our Computer Generated Diagnostic Assessment

Social Anxiety Disorder (Social Phobia) 300.23

This diagnosis is based on the following findings:
  • Had unreasonable fear of embarrassment or social anxiety
  • Exposure to the feared social situation always provoked strong anxiety
  • Recognized that this fear of embarrassment or social anxiety was excessive or unreasonable
  • Feared social situations were avoided or endured with intense anxiety
  • Fear of embarrassment or social anxiety occurred in most social situations
  • Fear of embarrassment or social anxiety caused clinically significant disability or distress
  • Fear of embarrassment or social anxiety was not due to another mental disorder
  • Fear of embarrassment or social anxiety was not due to substance use or other treatment
  • Fear of embarrassment or social anxiety was not due to a general medical condition

TREATMENT GOALS:

  • Goal: prevent unreasonable fear of embarrassment or social anxiety.

  • Goal: prevent strong anxiety when exposed to the feared social situation.

  • Goal: prevent avoidance of feared social situations (or endurance of them with intense anxiety).


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Social Phobias F40.1 - ICD10 Description, World Health Organization

Fear of scrutiny by other people leading to avoidance of social situations. More pervasive social phobias are usually associated with low self-esteem and fear of criticism. They may present as a complaint of blushing, hand tremor, nausea, or urgency of micturition, the patient sometimes being convinced that one of these secondary manifestations of their anxiety is the primary problem. Symptoms may progress to panic attacks.
Social Anxiety Disorder (Social Phobia) - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with social anxiety disorder (social phobia) needs to meet all of the following criteria:

  • Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.

  • The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).

  • The social situations almost always provoke fear or anxiety. Note: In children, the fear or anxiety may be experienced by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.

  • The social situations are avoided or endured with intense fear or anxiety.

  • The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

  • The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

  • The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functiioning.

  • The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

  • The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.

  • If another medical condition (e.g., Parkinson's disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clarly unrelated or is excessive.


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Diagnostic Features

Social Anxiety Disorder (Social Phobia) is a condition characterized by a marked and persistent fear of situations in which the individual is exposed to unfamiliar people or to possible scrutiny by others. The individual fears being humiliated or embarrassed, which leads to avoidance of social situations. Blushing is a hallmark physical response of social anxiety disorder. The individual recognizes that this fear is excessive or unreasonable. The feared social or performance situations are avoided or else are endured with intense anxiety or distress. Social phobia is usually associated with low self-esteem and fear of criticism. This disorder may present with complaints of blushing, hand tremor, nausea, or urgency of micturition. Symptoms may progress to panic attacks. Symptoms must have persisted for at least 6 months before is disorder is diagnosed. This diagnosis should not be given if the fear is reasonable given the context of the stimuli (e.g., fear of being called on in class when unprepared). The disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. This disorder is not due to a medical condition, medication, or abused substance. It is not better accounted for by another mental disorder (e.g., Panic Disorder, Body Dysmorphic Disorder, or Autism Spectrum Disorder). Often individuals with this disorder may develop substance abuse or depression.

Warning: Self-diagnosis of this disorder is often inaccurate. Accurate diagnosis of this disorder requires assessment by a qualified practitioner trained in psychiatric diagnosis and evidence-based treatment. However, if no such professional is available, our free computerized diagnosis is usually accurate when completed by an informant who knows the patient well. Computerized diagnosis is less accurate when done by patients (because they often lack insight).

Typical Fears

  • Social Interactions Scare The Individual:
    • Parties and social events
    • Talking to strangers
    • Talking to people in authority
    • Being criticized
    • Having heart palpitations when around people
  • Is Embarrassed By:
    • Blushing in front of people
    • Sweating in front of people
    • Doing things when people might be watching
    • Trembling or shaking in front of others
  • Fears Performing In Front Of Others:
    • Avoids being the centre of attention
    • Avoids giving speeches
    • Fears being embarrassed or looking stupid

Core Problems

  • Social and/or Occupational Impairment [ 1, 2, 3 ]
  • Phobia (Excessive Fear of Specific Social Situations) [ 4, 5 ]

Complications

Individuals with this disorder may develop hypersensitivity to criticism, negative evaluation, or rejection. They often have difficulty being assertive; and have a low self-esteem or have feelings of inferiority. They often fear indirect evaluation by others, such as taking a test. They may have poor social skills (e.g., poor eye contact) or observable signs of anxiety (e.g., cold clammy hands, tremors, shaky voice). They may underachieve at school due to test anxiety or avoidance of classroom participation. They may underachieve at work because of anxiety during, or avoidance of, speaking in groups, in public, or to authority figures and colleagues. They often have few friends and are less likely to marry. In more severe cases, individuals may drop out of school, be unemployed and not seek work due to difficulty interviewing for jobs, have no friends or cling to unfulfilling relationships, completely refrain from dating, or remain with their family of origin.

Comorbidity

Females have comorbid depressive, bipolar, and anxiety disorders, whereas males are more likely to fear dating, have oppositional defiant disorder or conduct disorder, and use alcohol and illicit drugs to relieve symptoms of this disorder. The following disorders frequently are associated with social anxiety disorder:

Associated Laboratory Findings

No laboratory test has been found to be diagnostic of this disorder.

Prevalence

The 12-month prevalence of Social Anxiety Disorder for America is 7%. Most individuals with this disorder fear public speaking, whereas somewhat less than half fear speaking to strangers or meeting new people. Other performance fears (e.g., eating, drinking, or writing in public, or using a public restroom) appear to be less common. In outpatient clinics, rates of Social Phobia have ranged between 10% and 20% of individuals with Anxiety Disorders. Social Anxiety Disorder is rarely the reason for admission to inpatient settings

Course

The median age of onset in America is 13, sometimes emerging out of a childhood history of social inhibition or shyness. However, some experience an onset in early childhood. Onset may abruptly follow a stressful or humiliating experience, or it may be insidious. The course may fluctuate with life stressors. For example, this disorder may diminish after a person with fear of dating marries and reemerge after death of a spouse.

Outcome

In the community, 30% recover within 1 year, and 50% recover within a few years.

Familial Pattern

Social Anxiety Disorder is heritable. First-degree relatives have a 2 to 6 times greater chance of having this disorder.

Effective Therapies

Cognitive behavioral therapy (CBT), SSRI and SNRI antidepressant medication have all proven to be effective in the treatment of this disorder. Often a combination of CBT plus antidepressant medication is used.

Ineffective therapies

Vitamins and dietary supplements are ineffective for this disorder.

A Dangerous Cult


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Treatment

Treatment Guidelines

Treatment

Summary Of NICE Social Anxiety Treatment Recommendations (2013)

Interventions for Adults With Social Anxiety Disorder

Treatment Principles

All interventions for adults with social anxiety disorder should be delivered by competent practitioners. Psychological interventions should be based on the relevant treatment manual(s), which should guide the structure and duration of the intervention. Practitioners should consider using competence frameworks developed from the relevant treatment manual(s) and for all interventions should:

  • Receive regular, high-quality outcome-informed supervision
  • Use routine sessional outcome measures (for example, the SPIN or LSAS) and ensure that the person with social anxiety is involved in reviewing the efficacy of the treatment
  • Engage in monitoring and evaluation of treatment adherence and practitioner competence – for example, by using video and audio tapes, and external audit and scrutiny if appropriate.

Initial Treatment Options for Adults With Social Anxiety Disorder

Offer adults with social anxiety disorder individual cognitive behavioural therapy (CBT) that has been specifically developed to treat social anxiety disorder (based on the Clark and Wells model or the Heimberg model; see recommendations below under "Delivering Psychological Interventions for Adults").

Do not routinely offer group CBT in preference to individual CBT. Although there is evidence that group CBT is more effective than most other interventions, it is less clinically and cost effective than individual CBT.

For adults who decline CBT and wish to consider another psychological intervention, offer CBT-based supported self-help (see recommendation below under "Delivering Psychological Interventions for Adults").

For adults who decline cognitive behavioural interventions and express a preference for a pharmacological intervention, discuss their reasons for declining cognitive behavioural interventions and address any concerns.

If the person wishes to proceed with a pharmacological intervention, offer a selective serotonin reuptake inhibitor (SSRI) (escitalopram or sertraline). Monitor the person carefully for adverse reactions (see recommendations below under "Prescribing and Monitoring Pharmacological Interventions in Adults").

For adults who decline cognitive behavioural and pharmacological interventions, consider short-term psychodynamic psychotherapy that has been specifically developed to treat social anxiety disorder (see recommendation below under "Delivering Psychological Interventions for Adults"). Be aware of the more limited clinical effectiveness and lower cost effectiveness of this intervention compared with CBT, self-help and pharmacological interventions.

Options for Adults With No or a Partial Response to Initial Treatment

For adults whose symptoms of social anxiety disorder have only partially responded to individual CBT after an adequate course of treatment, consider a pharmacological intervention (see recommendation above under "Initial treatment options for adults with social anxiety disorder") in combination with individual CBT.

For adults whose symptoms have only partially responded to an SSRI (escitalopram or sertraline) after 10 to 12 weeks of treatment, offer individual CBT in addition to the SSRI.

For adults whose symptoms have not responded to an SSRI (escitalopram or sertraline) or who cannot tolerate the side effects, offer an alternative SSRI (fluvoxamine1 or paroxetine) or a serotonin noradrenaline reuptake inhibitor (SNRI) (venlafaxine), taking into account:

  • The tendency of paroxetine and venlafaxine to produce a discontinuation syndrome (which may be reduced by extended-release preparations)
  • The risk of suicide and likelihood of toxicity in overdose

For adults whose symptoms have not responded to an alternative SSRI or an SNRI, offer a monoamine oxidase inhibitor (phenelzine2 or moclobemide).

Discuss the option of individual CBT with adults whose symptoms have not responded to pharmacological interventions.

1 At the time of publication (May 2013) fluvoxamine did not have a UK marketing authorisation for use in adults with social anxiety disorder. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented.

2 At the time of publication (May 2013) phenelzine did not have a UK marketing authorisation for use in adults with social anxiety disorder. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented.

Delivering Psychological Interventions for Adults

Individual CBT (the Clark and Wells model) for social anxiety disorder should consist of up to 14 sessions of 90 minutes' duration over approximately 4 months and include the following:

  • Education about social anxiety
  • Experiential exercises to demonstrate the adverse effects of self-focused attention and safety-seeking behaviours
  • Video feedback to correct distorted negative self-imagery
  • Systematic training in externally focused attention
  • Within-session behavioural experiments to test negative beliefs with linked homework assignments
  • Discrimination training or rescripting to deal with problematic memories of social trauma
  • Examination and modification of core beliefs
  • Modification of problematic pre- and post-event processing
  • Relapse prevention

Individual CBT (the Heimberg model) for social anxiety disorder should consist of 15 sessions of 60 minutes' duration, and 1 session of 90 minutes for exposure, over approximately 4 months, and include the following:

  • Education about social anxiety
  • Cognitive restructuring
  • Graduated exposure to feared social situations, both within treatment sessions and as homework
  • Examination and modification of core beliefs
  • Relapse prevention

Supported self-help for social anxiety disorder should consist of:

  • Typically up to 9 sessions of supported use of a CBT-based self-help book over 3–4 months
  • Support to use the materials, either face to face or by telephone, for a total of 3 hours over the course of the treatment

Short-term psychodynamic psychotherapy for social anxiety disorder should consist of typically up to 25–30 sessions of 50 minutes' duration over 6–8 months and include the following:

  • Education about social anxiety disorder
  • Establishing a secure positive therapeutic alliance to modify insecure attachments
  • A focus on a core conflictual relationship theme associated with social anxiety symptoms
  • A focus on shame
  • Encouraging exposure to feared social situations outside therapy sessions
  • Support to establish a self-affirming inner dialogue
  • Help to improve social skills

Prescribing and Monitoring Pharmacological Interventions in Adults

Before prescribing a pharmacological intervention for social anxiety disorder, discuss the treatment options and any concerns the person has about taking medication. Explain fully the reasons for prescribing and provide written and verbal information on:

  • The likely benefits of different drugs
  • The different propensities of each drug for side effects, discontinuation syndromes and drug interactions
  • The risk of early activation symptoms with SSRIs and SNRIs, such as increased anxiety, agitation, jitteriness and problems sleeping
  • The gradual development, over 2 weeks or more, of the full anxiolytic effect
  • The importance of taking medication as prescribed, reporting side effects and discussing any concerns about stopping medication with the prescriber, and the need to continue treatment after remission to avoid relapse

Arrange to see people aged 30 years and older who are not assessed to be at risk of suicide within 1–2 weeks of first prescribing SSRIs or SNRIs to:

  • Discuss any possible side effects and potential interaction with symptoms of social anxiety disorder (for example, increased restlessness or agitation)
  • Advise and support them to engage in graduated exposure to feared or avoided social situations.

After the initial meeting (see recommendation above), arrange to see the person every 2–4 weeks during the first 3 months of treatment and every month thereafter. Continue to support them to engage in graduated exposure to feared or avoided social situations.

For people aged under 30 years who are offered an SSRI or SNRI:

  • Warn them that these drugs are associated with an increased risk of suicidal thinking and self-harm in a minority of people under 30 and
  • See them within 1 week of first prescribing and
  • Monitor the risk of suicidal thinking and self-harm weekly for the first month (this recommendation is from the NICE clinical guideline 113.

Arrange to see people who are assessed to be at risk of suicide weekly until there is no indication of increased suicide risk, then every 2–4 weeks during the first 3 months of treatment and every month thereafter. Continue to support them to engage in graduated exposure to feared or avoided social situations.

Advise people taking a monoamine oxidase inhibitor of the dietary and pharmacological restrictions concerning the use of these drugs as set out in the British national formulary.

For people who develop side effects soon after starting a pharmacological intervention, provide information and consider 1 of the following strategies:

  • Monitoring the person's symptoms closely (if the side effects are mild and acceptable to the person)
  • Reducing the dose of the drug
  • Stopping the drug and offering either an alternative drug or individual CBT, according to the person's preference

This recommendation is adapted from the NICE clinical guideline 113.

If the person's symptoms of social anxiety disorder have responded well to a pharmacological intervention in the first 3 months, continue it for at least a further 6 months.

When stopping a pharmacological intervention, reduce the dose of the drug gradually. If symptoms reappear after the dose is lowered or the drug is stopped, consider increasing the dose, reintroducing the drug or offering individual CBT.

Identification and Assessment of Children and Young People

Identification of Children and Young People With Possible Social Anxiety Disorder

Health and social care professionals in primary care and education and community settings should be alert to possible anxiety disorders in children and young people, particularly those who avoid school, social or group activities or talking in social situations, or are irritable, excessively shy or overly reliant on parents or carers. Consider asking the child or young person about their feelings of anxiety, fear, avoidance, distress and associated behaviours (or a parent or carer) to help establish if social anxiety disorder is present, using these questions:

  • "Sometimes people get very scared when they have to do things with other people, especially people they don't know. They might worry about doing things with other people watching. They might get scared that they will do something silly or that people will make fun of them. They might not want to do these things or, if they have to do them, they might get very upset or cross."
    • "Do you/does your child get scared about doing things with other people, like talking, eating, going to parties, or other things at school or with friends?"
    • "Do you/does your child find it difficult to do things when other people are watching, like playing sport, being in plays or concerts, asking or answering questions, reading aloud, or giving talks in class?"
    • "Do you/does your child ever feel that you/your child can't do these things or try to get out of them?"

If the child or young person (or a parent or carer) answers 'yes' to one or more of the questions above, consider a comprehensive assessment for social anxiety disorder (see recommendations below under "Assessment of Children and Young People With Possible Social Anxiety Disorder").

If the identification questions (see first recommendation in this section) indicate possible social anxiety disorder, but the practitioner is not competent to perform a mental health assessment, refer the child or young person to an appropriate healthcare professional. If this professional is not the child or young person's GP, inform the GP of the referral.

Interventions for Children and Young People With Social Anxiety Disorder

Treatment Principles

All interventions for children and young people with social anxiety disorder should be delivered by competent practitioners. Psychological interventions should be based on the relevant treatment manual(s), which should guide the structure and duration of the intervention. Practitioners should consider using competence frameworks developed from the relevant treatment manual(s) and for all interventions should:

  • Receive regular high-quality supervision
  • Use routine sessional outcome measures, for example:
    • The LSAS–child version or the SPAI-C, and the SPIN or LSAS for young people
    • The MASC, RCADS, SCAS or SCARED for children
  • Engage in monitoring and evaluation of treatment adherence and practitioner competence – for example, by using video and audio tapes, and external audit and scrutiny if appropriate

Be aware of the impact of the home, school and wider social environments on the maintenance and treatment of social anxiety disorder. Maintain a focus on the child or young person's emotional, educational and social needs and work with parents, teachers, other adults and the child or young person's peers to create an environment that supports the achievement of the agreed goals of treatment.

Treatment for Children and Young People With Social Anxiety Disorder

Offer individual or group CBT focused on social anxiety (see recommendation below under the section "Delivering psychological interventions for children and young people") to children and young people with social anxiety disorder. Consider involving parents or carers to ensure the effective delivery of the intervention, particularly in young children.

Delivering Psychological Interventions for Children and Young People

Individual CBT should consist of the following, taking into account the child or young person's cognitive and emotional maturity:

  • 8–12 sessions of 45 minutes' duration
  • Psychoeducation, exposure to feared or avoided social situations, training in social skills and opportunities to rehearse skills in social situations
  • Psychoeducation and skills training for parents, particularly of young children, to promote and reinforce the child's exposure to feared or avoided social situations and development of skills

Group CBT should consist of the following, taking into account the child or young person's cognitive and emotional maturity:

  • 8–12 sessions of 90 minutes' duration with groups of children or young people of the same age range
  • Psychoeducation, exposure to feared or avoided social situations, training in social skills and opportunities to rehearse skills in social situations
  • Psychoeducation and skills training for parents, particularly of young children, to promote and reinforce the child's exposure to feared or avoided social situations and development of skills

Consider psychological interventions that were developed for adults (see "Interventions for Adults with Social Anxiety Disorder", above) for young people (typically aged 15 years and older) who have the cognitive and emotional capacity to undertake a treatment developed for adults.

Interventions That Are Not Recommended to Treat Social Anxiety Disorder

Do not routinely offer pharmacological interventions to treat social anxiety disorder in children and young people.

Do not routinely offer anticonvulsants, tricyclic antidepressants, benzodiazepines or antipsychotic medication to treat social anxiety disorder in adults.

Do not routinely offer mindfulness-based interventions or supportive therapy to treat social anxiety disorder (including mindfulness-based stress reduction and mindfulness-based cognitive therapy).

Do not offer St John's wort or other over-the-counter medications and preparations for anxiety to treat social anxiety disorder. Explain the potential interactions with other prescribed and over-the-counter medications and the lack of evidence to support their safe use.

Do not offer botulinum toxin to treat hyperhidrosis (excessive sweating) in people with social anxiety disorder. This is because there is no good-quality evidence showing benefit from botulinum toxin in the treatment of social anxiety disorder and it may be harmful.

Do not offer endoscopic thoracic sympathectomy to treat hyperhidrosis or facial blushing in people with social anxiety disorder. This is because there is no good-quality evidence showing benefit from endoscopic thoracic sympathectomy in the treatment of social anxiety disorder and it may be harmful.

Specific Phobias

Interventions That Are Not Recommended

Do not routinely offer computerised CBT to treat specific phobias in adults.


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This habit of planning your day in the morning, and reviewing your day in the evening, is a time-proven technique for more successful living.

Note: When each of the following videos finishes; you must exit YouTube (by manually closing the window) in order to return to this webpage.



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    "In physical science a first essential step in the direction of learning any subject is to find principles of numerical reckoning and practicable methods for measuring some quality connected with it. I often say that when you can measure what you are speaking about and express it in numbers you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind: it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science, whatever the matter may be."

    Lord Kelvin (1824 – 1907)


  • The best summary on bad research is given by Laura Arnold in this TEDx lecture. If you read nothing else about research, you owe it to yourself to watch this short video - it is excellent!

  • Canadian researchers who commit scientific fraud are protected by privacy laws: There are criminals in every community - even in the scientific research community (especially if a lot of money is at stake). Criminal researchers can hide their fraud behind outdated privacy laws.

  • The power of asking "what if?"

  • The active placebo effect: 2300 years ago, the Greek Stoic philosophers taught that it is not the objective event, but our subjective judgment about the event, that determines our behavior. The active placebo effect bears witness to this ancient wisdom.

  • Criteria For High Quality Research Studies

  • It is troubling that a recent study found that two-thirds of important psychological research studies couldn't be replicated. High quality research must meet the following criteria:

    • Randomized Controlled Trial:
      Ask: Was the trial randomized? Was the randomization procedure described and was it appropriate? The best research design is to have research subjects randomly assigned to an experimental or control group. It is essential that confounding factors be controlled for by having a control group or comparator condition (no intervention, placebo, care as usual etc.).

    • Representative Sample:
      Ask: Do the research subjects represent a normal cross-section of the population being studied? Many psychological research studies using university students are flawed because their subjects are not representative of the normal population since they are all W.E.I.R.D. (White, Educated, Intelligent, Rich, and living in a Democracy).

    • Single Blind Trial:
      Ask: Was the treatment allocation concealed? It is essential that the research subjects are kept "blind" as to whether they are in the experimental or control group (in order to control for any placebo effects).

    • Double Blind Trial (Better Than Single Blind Trial):
      Ask: Were blind outcome assessments conducted? In a double blind study, neither the research subjects nor the outcome assessors know if the research subject is in the experimental or control group. This controls for both the placebo effect and assessor bias.

    • Baseline Comparability:
      Ask: Were groups similar at baseline on prognostic indicators? The experimental and control groups must be shown to be comparable at the beginning of the study.

    • Confounding Factors:
      Ask: Were there factors, that weren't controlled for, that could have seriously distorted the study's results? For example, research studies on the effectiveness of mindfulness cognitive therapy in preventing depressive relapse forgot to control for whether the research subjects were also simultaneously receiving antidepressant medication or other psychological treatments for depression.

    • Intervention Integrity:
      Ask: Was the research study protocal strictly followed? The research subjects must be shown to be compliant (e.g., taking their pills, attending therapy) and the therapists must be shown to be reliably delivering the intervention (e.g., staying on the research protocol).

    • Statistical analysis:
      Ask: Was a statistical power calculation described? The study should discuss its statistical power analysis; that is whether the study size is large enough to statistically detect a difference between the experimental and control group (should it occur) and usually this requires at least 50 research subjects in the study.

      Ask: Are the results both statistically significant and clinically significant? The results should be both statistically significant (with a p-value <0.05) and clinically significant using some measure of Effect Size such as Standardized Mean Difference (e.g., Cohen's d >= 0.33). The summary statistics should report what percentage of the total variance of the dependent variable (e.g., outcome) can be explained by the independent variable (e.g., intervention). In clinical studies, the study should report the number needed to treat for an additional beneficial outcome (NNTB), and the number needed to treat for an additional harmful outcome (NNTH).

        Number Needed To Benefit (NNTB): This is defined as the number of patients that need to be treated for one of them to benefit compared with a control in a clinical trial. (It is defined as the inverse of the absolute risk reduction.) Note: Statistically, the NNTB depends on which control group is used for comparison - e.g., active treatment vs. placebo treatment, or active treatment vs. no treatment.

        Number Needed To Harm (NNTH): This is defined as the number of patients that need to be treated for one of them to be harmed compared with a control in a clinical trial. (It is defined as the inverse of the absolute increase in risk of harm.)

        Tomlinson found “an NNTB of 5 or less was probably associated with a meaningful health benefit,” while “an NNTB of 15 or more was quite certain to be associated with at most a small net health benefit.”

      Ask: Does the researcher accept full responsibility for the study's statistical analysis? The researcher should not just hand over the study's raw data to a corporation (that may have $1,000 million invested in the study) to do the statistical analysis.

    • Completeness of follow-up data:
      Ask: Was the number of withdrawals or dropouts in each group mentioned, and were reasons given for these withdrawals or dropouts? Less than 20% of the research subjects should drop out of the study. The intervention effect should persist over an adequate length of time.

    • Handling of missing data:
      Ask: Was the statistical analysis conducted on the intention-to-treat sample? There must be use of intention-to-treat analysis (as opposed to a completers-only analysis). In this way, all of the research subjects that started the study are included in the final statistical analysis. A completers-only analysis would disregard those research subjects that dropped out.

    • Replication of Findings:
      Ask: Can other researchers replicate this study's results? The research study's methodology should be clearly described so that the study can be easily replicated. The researcher's raw data should be available to other researchers to review (in order to detect errors or fraud).

    • Fraud:
      Ask: Is there a suspicion of fraud? In a research study, examine the independent and dependent variables that are always measured as a positive whole number (e.g., a variable measured on a 5-point Likert-type scale ranging from "1 = definitely false to 5 = definitely true" etc.). For each of these variables, look at their sample size (n), mean (M) and standard deviation (SD) before they undergo statistical analysis. There is a high suspicion of fraud in a study's statistics:

      • If the M is mathematically impossible (online calculator): This is one of the easiest ways to mathematically detect fraud. The mean (M) is defined as "the sum (Sum) of the values of each observation divided by the total number (n) of observations". So: M = Sum/n. Thus: (Sum) = (M) multiplied by (n). We know that, if a variable is always measured as a positive whole number, the sum of these observations always has to be a whole number. For these variables to test for fraud: calculate (M) multiplied by (n). This calculates the Sum which MUST be a positive whole number. If the calculated Sum isn't a positive whole number; the reported mean (M) is mathematically impossible - thus the researcher either cooked the data or made a mistake. A recent study of 260 research papers published in highly reputable psychological journals found that 1 in 2 of these research papers reported at least one impossible value, and 1 in 5 of these research papers reported multiple impossible values. When the authors of the 21 worst offending research papers were asked for their raw data (so that its reliability could be checked) - 57% angrily refused. Yet such release of raw data to other researchers is required by most scientific journals. (Here is an example of a research paper filled with mathematically impossible means.)

      • If the SD is mathematically impossible (online calculator): When researchers fraudulently "cook" their data, they may accidently give their data a mean and standard deviation that is mathematically impossible for a (normally distributed) strictly positive variable (because the "cooked" M and SD would mathematically require the strictly positive variable's range of data to include negative numbers). For a normally distributed sample of size of 25-70, this occurs when the SD is greater than one-half of the M; for a sample size of 70+, this occurs when the SD is greater than one-third of the M [using these formulas].

      • If the SD/M is very small (i.e., the variable's standard deviation is very small compared to the mean suggesting data smoothing).

      • If the SD's are almost identical (i.e., the variables have different means but almost identical standard deviations).

      • If the 4th digit of the values of the variables aren't uniformly distributed - since each should occur 10% of the time (Benford's Law).

      • If the researcher is legally prevented from publishing negative findings about a drug or therapy because that would violate the "nondisclosure of trade secrets" clause in the research contract (i.e., it is a "trade secret" that the drug or therapy is ineffective - hence this can not be "disclosed"). Approximately half of all registered clinical trials fail to publish their results.

      • If the researcher refuses to release his raw data to fellow researchers (so that they can check its validity). In order to be published in most scientific journals, a researcher must promise to share his raw data with fellow researchers. Thus a researcher's refusal to do so is almost a sure indicator of fraud.

      • If the research study's data contradicts the study's own conclusions - surprisingly, this often occurs.

  • Calling Bullshit In The Age of Big Data - "Bullshit is language, statistical figures, data graphics, and other forms of presentation intended to persuade by impressing and overwhelming a reader or listener, with a blatant disregard for truth and logical coherence." Reading the syllabus of this university course should be required reading for every student of mental health. This syllabus is absolutely fantastic!

  • Statistical Methods in Psychology Journals: Guidelines and Explanations - American Psychologist 1999

  • Not All Scientific Studies Are Created Equal - video

  • The efficacy of psychological, educational, and behavioral treatment

  • Estimating the reproducibility of psychological science

  • Psychologists grapple with validity of research

  • Industry sponsorship and research outcome (Review) - Cochrane Library

  • 'We've been deceived': Many clinical trial results are never published - (text and video)

  • Junk science misleading doctors and researchers

  • Junk science under spotlight after controversial firm buys Canadian journals

  • Medicine with a side of mysticism: Top hospitals promote unproven therapies - Are some doctors becoming modern witchdoctors?

  • When Evidence Says No, But Doctors Say Yes


  • Cochrane Collaboration - the best evidence-based, standardized reviews available

Research Topics

Social Anxiety Disorder - Latest Research (2016-2017)


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Which Behavioral Dimensions Are Involved?

Research has shown that there are 5 major dimensions (the "Big 5 Factors") of personality disorders and other mental disorders. There are two free online personality tests that assess your personality in terms of the "Big 5 dimensions of personality". Although not computerized online, the Big Five Inventory (BFI) is a 44-item test often used in personality research.

This website uses these 5 major dimensions of human behavior to describe all mental disorders. (This website adds one more dimension, "Physical Health", but our discussion will focus on the first 5 major dimensions.)

These major dimensions of human behavior seem to represent the major dimensions whereby our early evolutionary ancestors chose their hunting companions or spouse. To maximize their chance for survival, our ancestors wanted companions who were agreeable, conscientious, intelligent, sociable, emotionally stable, and physically healthy.

    Dimensions of Human Behavior That Are Impaired in Social Anxiety Disorder

    THE POSITIVE SIDE OF THE "BIG 5" PERSONALITY DIMENSIONS THE NEGATIVE SIDE OF THE "BIG 5" PERSONALITY DIMENSIONS THIS DISORDER
    Agreeableness Antagonism       Agreeableness
    Conscientiousness Disinhibition       Conscientiousness
    Intellect Decreased Intellect       Intellect
    Sociability (Extraversion) Detachment       Detachment
    Emotional Stability Negative Emotion       Negative Emotion

The 5 Major Dimensions of Mental Illness

The Big 5 Factors or dimensions of mental illness each has a healthy side and an unhealthy side. Thus the Big 5 Factors are: (1) Agreeableness vs. Antagonism, (2) Conscientiousness vs. Disinhibition, (3) Intellect vs. Decreased Intellect, (4) Sociability (Extraversion) vs. Detachment (Introversion), and (5) Emotional Stability vs. Negative Emotion.

The Following Will Only Discuss The Dimensions of Mental Illness That Are Abnormal In This Disorder

The problems that are diagnostic of this disorder are highlighted in   Pink  . Other problems that are often seen in this disorder are highlighted in   Yellow  .



Treatment Goals for Individuals With Detachment

SOCIABILITY (EXTRAVERSION) VS. DETACHMENT
.
SOCIABILITY
.
Description: Sociability (Extraversion) is synonymous with being enthusiastic and assertive. Assertiveness encompasses traits relating to leadership, dominance, and drive. Enthusiasm encompasses both sociability and the tendency to experience and express positive emotion. Extraverts tend to engage in social interaction; they are enthusiastic, risk-taking, talkative and assertive. The Extraversion dimension measures the behaviors that are central to the concept of SOCIABILITY - seeking and enjoying companionship. High sociability is associated with better: longevity, leadership, job [sales] performance. (This dimension appears to measure the behaviors that differentiate approach from avoidance.)
Descriptors: Sociable, gregarious, reward-seeking, talkative.
Language Characteristics: Many topics, higher verbal output, think out loud, pleasure talk, agreement, compliment, positive emotion words, sympathetic, concerned about hearer (but not empathetic), simple constructions, few unfilled pauses, few negations, few tentative words, informal language, many swear words, exaggeration (e.g. "I'm really smart" ), many words related to humans (e.g. "man", "pal"). poor vocabulary.
Research: Higher scores on Sociability (extraversion) are associated with greater happiness and broader social connections. *MRI research found that Sociability (extraversion) was associated with increased volume of medial orbitofrontal cortex, a region involved in processing reward information.
"I'm talkative"
"I'm not reserved."
"I'm full of energy."
"I generate a lot of enthusiasm."
"I'm not quiet."
"I have an assertive personality."
"I'm not shy or inhibited."
"I am outgoing and sociable."
"I make friends easily."
"I warm up quickly to others."
"I show my feelings when I'm happy."
"I have a lot of fun."
"I laugh a lot."
"I take charge."
"I have a strong personality."
"I know how to captivate people."
"I see myself as a good leader."
"I can talk others into doing things."
"I am the first to act."
.
Attention Seeking
.
"I like to draw attention to myself."
"I crave attention."
"I do things to make sure people notice me."
"I do things so that people just have to admire me."
"My behavior is often bold and grabs peoples' attention."
.
DETACHMENT
.
Description: Detachment is synonymous with being reserved and quiet.
Descriptors: Withdrawn, anhedonic (pleasureless), intimacy avoiding, detached, shy, passive, solitary, moody
Language Characteristics: Single topic, doesn't think out loud, problem talk, dissatisfaction, negative emotion words, not sympathetic, elaborated sentence constructions, many unfilled pauses, formal language, many negations, many tentative words (e.g. maybe, guess), few swear words, little exaggeration, few words related to humans, rich vocabulary.
.
* Social Withdrawal:
"I don’t like to get too close to people."
"I don't deal with people unless I have to."
"I'm not interested in making friends."
"I don’t like spending time with others."
"I say as little as possible when dealing with people."
"I keep to myself."
"I am hard to get to know."
"I reveal little about myself."
"I do not have an assertive personality."
"I lack the talent for influencing people."
"I wait for others to lead the way."
"I hold back my opinions."
.
* Intimacy Avoidance:
"I steer clear of romantic relationships."
"I prefer to keep romance out of my life."
"I prefer being alone to having a close romantic partner."
"I'm just not very interested in having sexual relationships."
"II break off relationships if they start to get close."
.
* Loss of Interest or Pleasure:
"I often feel like nothing I do really matters."
"I almost never enjoy life."
"Nothing seems to make me feel good."
"Nothing seems to interest me very much."
"I almost never feel happy about my day-to-day activities."
"I rarely get enthusiastic about anything."
"I don't get as much pleasure out of things as others seem to."
.
* Restricted Emotions:
"I don't show emotions strongly."
"I don't get emotional."
"I never show emotions to others."
"I don't have very long-lasting emotional reactions to things."
"People tell me it's difficult to know what I'm feeling."
"I am not a very enthusiastic person."
.
("Sociability vs. Detachment" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.



Treatment Goals for Individuals With Negative Emotion

EMOTIONAL STABILITY VS. NEGATIVE EMOTION
.
EMOTIONAL STABILITY
.
Description: Emotional Stability is synonymous with being calm and emotionally stable. The Emotional Stability dimension measures the behaviors that are central to the concept of COURAGE - having calm composure and endurance when confronting adversity. High emotional stability is associated with better: longevity, leadership, job [team] performance, and marital success. (This dimension appears to measure the behaviors that differentiate safety from danger.)
Descriptors: Calm, even-tempered, peaceful, confident
Language Characteristics: Pleasure talk, agreement, compliment, low verbal productivity, few repetitions, neutral content, calm, few self-references, many short silent pauses, few long silent pauses, many tentative words, few aquiescence, little exaggeration, less frustration, low concreteness.
"I am relaxed, and I handle stress well."
"I am emotionally stable, and not easily upset."
"I remain calm in tense situations."
"I rarely get irritated."
"I keep my emotions under control."
"I rarely lose my composure."
"I am not easily annoyed."
"I seldom feel blue."
"I feel comfortable with myself."
"I rarely feel depressed."
"I am not embarrassed easily."
.
NEGATIVE EMOTION
.
Description: Degree to which people experience persistent anxiety or depression and are easily upset. (This could be thought of as high threat sensitivity or low stress tolerance.)
Descriptors: Emotionally unstable, anxious, separation-insecure, depressed, self-conscious, oversensitive, vulnerable.
Language Characteristics: Problem talk, dissatisfaction, high verbal productivity, many repetitions, polarised content, stressed, many self-references, few short silent pauses, many long silent pauses, few tentative words, more aquiescence, many self references, exaggeration, frustration, high concreteness.
Research: Lower scores on Emotional Stability are associated with unhappiness, dysfunctional relationships, and mental health problems. *MRI research found that Low Emotional Stability (= Negative Emotion or Neuroticism) was associated with increased volume of brain regions associated with threat, punishment, and negative emotions.
.
* Emotional Instability:
"I get emotional easily, often for very little reason."
"I get emotional over every little thing."
"My emotions are unpredictable."
"I never know where my emotions will go from moment to moment."
"I am a highly emotional person."
"I have much stronger emotional reactions than almost everyone else."
"My emotions sometimes change for no good reason."
"I get angry easily."
"I get upset easily."
"I change my mood a lot."
"I am a person whose moods go up and down easily."
"I get easily agitated."
"I can be stirred up easily."
.
* Anxiety:
"I worry about almost everything."
"I'm always fearful or on edge about bad things that might happen."
"I always expect the worst to happen."
"I am a very anxious person."
"I get very nervous when I think about the future."
"I often worry that something bad will happen due to mistakes I made in the past."
"I am filled with doubts about things."
"I feel threatened easily."
"I am afraid of many things."
.
* Separation Insecurity:
"I fear being alone in life more than anything else."
"I can't stand being left alone, even for a few hours."
"I’d rather be in a bad relationship than be alone."
"I'll do just about anything to keep someone from abandoning me."
"I dread being without someone to love me."
.
* Submissiveness:
"I usually do what others think I should do."
"I do what other people tell me to do."
"I change what I do depending on what others want."
.
* Perseveration:
"I get stuck on one way of doing things, even when it's clear it won't work."
"I get stuck on things a lot."
"It is hard for me to shift from one activity to another."
"I get fixated on certain things and can’t stop."
"I feel compelled to go on with things even when it makes little sense to do so."
"I keep approaching things the same way, even when it isn’t working."
.
* Depressed Mood:
"I have no worth as a person."
"Everything seems pointless to me."
"I often feel like a failure."
"The world would be better off if I were dead."
"The future looks really hopeless to me."
"I often feel just miserable."
"I'm very dissatisfied with myself."
"I often feel like nothing I do really matters."
"I know I'll commit suicide sooner or later."
"I talk about suicide a lot."
"I feel guilty much of the time."
"I'm so ashamed by how I've let people down in lots of little ways."
"I am easily discouraged."
"I become overwhelmed by events."
.
("Emotional Stability vs. Negative Emotion" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.


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