PDF | A greater understanding of the origins of social phobia is much ized social phobia situated at one end and avoidant personality disor-. Social anxiety disorder, also known as social phobia, is one of the most In social anxiety disorder, the fear can occur in vir . soclallunctioning end dioablilly . social phobia offered by the Clinical Research Unit for Anxiety Disorders at St . What you can expect by the end of this program is for your symptoms to have.
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People with social anxiety tend to fear and avoid social situations. They are very concerned that . It's not the end of the world. We all say silly things and most of. other kinds of anxiety disorders, please see the end of this booklet. Social Phobia . Page 4. Social Phobia. Social phobia is a strong fear of being judged by others and of being . You can browse online, download documents in PDF, and order . Social anxiety is a common disorder characterized by a persistent and excessive fear of one or .. tary–adrenal (HPA) axes, and their respective end products.
Virtual Reality VR was used in this study as a therapeutic tool in a behavior-analytic intervention with two subjects who had social anxiety disorder. The goals were to assess the therapeutic effects of the intervention program and the VR simulator with regard to the ability to generate sense of presence and anxiety responses. The program consisted of: Sense of presence, anxiety and galvanic skin response were reported in each exposure therapy session and anxiety, depression and social phobia inventories were reported at the end of each stage. Functional analyses were formulated based on behaviors occurring in social contexts between sessions.
According to the authors, the satisfactory result of the study was only possible because of the strategies applied. These included control of the environment together with the establishment of a hierarchy of events causing anxiety. Lack of control of the natural environment can make exposure very aversive, leading to an avoidance response to the treatment condition itself Anderson et al. Treatment programs using VR as a therapeutic tool, in turn, allow the control of some interaction contingencies between the user and the avatar simulated character , which are useful in social anxiety disorder treatment programs.
A recent study conducted by Roy et al. An experimental group G1 exposed to an intervention protocol of 12 sessions of VR was compared with another experimental group G2 exposed to an intervention based on Cognitive Behavior Therapy CBT and to a third group G3 that was not subject to an intervention waiting list. In this experiment the three groups received post-test assessment and the average scores obtained by applying the Liebowitz Social Anxiety Scale were clearly reduced in the experimental groups G1 and G2 in relation to G3, with no statistical significance between G1 and G2.
Similar results were found by other studies that also compared the effectiveness of VR and CBT in the treatment of social anxiety disorder e. These studies demonstrated that therapeutic effect can be found in interventions using VR, as well as in interventions using other therapies such as CBT. Notwithstanding, different results were obtained by Kampmann et al. Kampmann et al. Sixty participants diagnosed as having social anxiety disorder were randomly distributed between three groups, namely two treatment groups and one control group waiting list.
The VRET procedure was conducted in scenarios that enabled spoken interaction with virtual human beings avatars whilst the IVET procedure was conducted in real-life situations similar to the virtual ones. Both procedures were conducted in individual therapy. When the results of the groups that received treatment were compared by analyzing the assessments done before and after the interventions, both were found to have reduced avoidance behaviors, increased duration of speaking interactions and reduced perceived stress, when compared to the waiting list group.
The participants who received IVET, but not those who received VRET, improved regarding fear of being negatively assessed, speaking performance, reduced overall anxiety and depression in relation to those on the waiting list.
The studies described above have demonstrated that treatments using VR can be effective. Their results were obtained through tests, inventories and self-reporting questionnaires, and physiological measurements, such as heart rate and skin conductance responses.
A study conducted by Wiederhold et al. Heart rate, galvanic skin response and body temperature of 22 non-phobic participants and 36 phobic participants were monitored over six sessions of exposure to VR.
The authors reported significant difference between the galvanic skin response measurements of phobic and non-phobic participants during exposure to VR.
The physiological measurements returned to baseline levels among the non-phobic participants, whilst they remained at higher levels for longer among the phobic participants. At the end of the intervention, 33 of the 36 phobic participants showed clinical improvement However, assessment of the galvanic response was done based on group averages.
Based on investigations into the use of VR technology applied to the context of clinical interventions Barbosa, ; Kampmann et al. The study participants were two male university students aged 20 and 27, referred to as P1 e P2, respectively. Participant 1 P1 was 20 years old, single he was dating university student. He had been living with his brothers since he began studying when he was Until then he had lived with his parents in a small inner-state town.
During any spoken interaction with them he avoided eye contact and as a consequence these interactions were sporadic and brief. The same pattern repeated itself with teachers, other relatives, his music teacher he had keyboard and singing lessons.
P1 reported fear of speaking in seminars and his academic and artistic presentations were preceded by considerable anxiety. In the same way as happened in his presentations, all his spoken interaction was marked by tachycardia, loss of voice, shaking, fear, freezing, he felt insecure, reported low self-esteem and avoided situations.
P2 was a 27 year-old single he was dating university student. He shared a house with two other people, with whom he had no close contact. Prior to this he had lived with his mother in the state capital. He reported that it had taken him three years more than expected to finish high school.
He had moved from one town to another and changed schools many times during his school years and felt particular difficulty with social interaction in those environments.
He felt very uncomfortable going into and remaining in classrooms, because of the imminent interaction with his fellow students, having to talk about himself and about everyday subjects. This type of interaction made him feel shaky, go red, his legs wobbled and he felt anxiety.
He had undergone psychotherapy several times since he was 16 years-old - the last time was a few years ago - with the aim of treating his social anxiety disorder, but without success.
In addition, He felt difficulty in going to and remaining in restaurants, handling cutlery and eating in front of other people. The sessions were held in a room of the Psychology Clinic of a public university. The room had two chairs and a table for the material and equipment needed for the sessions. The simulator showed specific scenarios designed for the treatment of social anxiety disorder. The scenarios shown had contexts for possible social interactions by the participant with avatars and possible performance of predetermined tasks.
The scenarios were designed to follow a sequence of events, although nothing prevented them from being shown in an alternative order. The first scene consisted of a shopping center food court without any avatars; with effect from the second scene avatars were gradually introduced. The second scene consisted of an automated teller machine that could be operated, located in a food court; the third scene took place in one of the food court snack bars; the fourth and fifth scenes happened in part of the same food court where there were tables and chairs.
The instruments specified as follows were used to measure behaviors. Scores closer to 0 indicated no level of anxiety whilst scores closer to 10 indicated higher levels of anxiety. The Sense of Presence Inventory SPI consisted of 14 items describing exposure to VR in terms of virtual stimuli, real-life stimuli, physiological reactions during exposure and behavior shown throughout exposure.
Answers were given according to a Likert scale from 0 totally disagree to 4 totally agree. The total score showed the extent to which the participants felt themselves to be present in the virtual environment.
BAI was comprised of 21 items using a Likert scale of 0 to 3. A total score of 0 to 10 corresponded to the Minimum level; 11 to 19, Mild; 20 to 30, Moderate; 31 to 63, Severe. BDI was comprised of 21 items using a Likert scale of 0 to 3. A total score of 0 to 11 corresponded to the Minimum level; 12 to 19, Mild; 20 to 35, Moderate; 36 to 63, Severe. SPIN was comprised of 17 items using a Likert scale from 0 to 4 and a total score of greater than 19 indicated the presence of these symptoms.
The Behavior Recording Chart consisted of a sheet of paper on which the participant reported social interaction situations that he had faced or avoided between one session and the next, so as to enable functional analyses and verify whether the intervention could be generalized to other contexts.
The program was comprised of one initial session; five baseline sessions; eight intervention sessions with exposure to VR; one closing session; two follow-up sessions, one of which occurred one month after the closing session and the other three months after the closing session. The number of sessions in each stage of the procedure served as a reference and was sensitive to the needs of each participant.
For both participants, the initial session and the closing session were conducted in two stages, given that the application of the tests and inventories also took place in them. Initial Session. The initial session consisted of a semi-structured interview followed by a presentation of the study, its objectives and procedures. Baseline Stage. The baseline was comprised of five sessions.
Therapy simulator. The instruction given to the participant was to.
At the beginning, avoid sudden head movements, as you may experience discomfort, such as dizziness. Once exposure had ended, the biofeedback device remained switched on for a further 40 seconds to enable stabilization of the data collected. The participant answered the SUDS and SPI instruments immediately following exposure to VR, as well as being sounded with the aim of investigating their experience with the simulator and accessories. Intervention Stage. During the intervention stage, apart from exposure to VR, other therapeutic resources were introduced: These resources comprised the intervention program.
The participant was taught diaphragmatic breathing during the first session of the intervention stage. This consisted of explaining how to use the diaphragm muscle when breathing, facilitating the entry of air into the lungs and greater oxygenation with less effort. To this end the instruction was given to:. Try to notice how relaxing it is to pay attention to your breathing, and just how much you have control over it, feel your entire body contributing to your breathing, relaxing, concentrate on this sensation of pleasure.
The VR exposure intervention procedure consisted of: In the same way as during the baseline stage, the biofeedback device was switched on 40 seconds before exposure to VR and switched off 40 seconds after exposure had ended. The exposure scenarios simulated social interactions and the performance of activities in a simulated social context. The scenes were divided into exposures capable of producing scrutiny anxiety Scene 2 , assertiveness anxiety Scene 3 , performance anxiety Scene 4 intimacy anxiety Scene 5.
The order of the scenarios was adjusted based on what had been reported in the initial session, according to the degree of progressive difficulty in dealing with situations. The same sequence was used for both participants. Exposure to VR could be interrupted at any time by the participant or researcher if the participant showed signs of not feeling well nausea, headache, dizziness, for example , if exposure was more aversive than the participant was able to stand or for other reasons presented by the participant.
However, interruption was not necessary during the intervention. This evaluation consisted of an oral investigation, using questions of the following nature: Closing Session.
Follow-Up Sessions. These were held one and three months after the last session involving VR. In these sessions the participant was exposed once again to the VR scenarios, preceded by the diaphragmatic breathing exercise and with monitoring of the galvanic skin response. The Behavior Recording Chart was presented during the first intervention session and the participants were instructed to fill it in between one session and the next, with the aim of providing input for the formulation of functional analyses in the following sessions with the participant.
From the second intervention session up to the final follow-up session, P1 delivered nine completed Recording Charts with 4, 4, 1, 2, 3, 4, 2, 4 and 4 behavioral episodes, respectively. P2 handed in two completed charts with one behavioral episode described on each one. The behavioral episodes reported by P1 on the Recording Charts occurred, for the most part, in a context of intimacy and in the performance of activities in a social context.
The situations that P1 reported most frequently were doing presentations of assignments in the classroom, spoken interactions with fellow students and family members, as well as spoken interactions about his sexual orientation. In the episodes described on Charts 1, 2 and 3, which described conversations with friends about sexual orientation, antecedents were found to be: A number of cognitive accounts have been put forward to try to explain this Clark and Wells ; Heimberg et al.
There is considerable overlap amongst these models, for example they all highlight the importance of fear of negative evaluation and of self-focused attention in maintaining social anxiety. A useful review of the prominent cognitive behavioural models including a description of their commonalities and differences is provided by Wong and Rapee According to the cognitive model developed by Clark and Wells , people with social anxiety hold firm beliefs about the importance of making a good impression to others, but they also believe they come across badly Leary These negative beliefs are activated in social settings and understandably trigger alarm Hofmann The sense of threat then motivates a chain of cognitive, affective and behavioural responses.
This chain of responses is self-perpetuating and closed off to new information. These are described in more detail below, and the model is displayed in Fig. As a result, individuals often fail to observe that other people are responding to them in a broadly benign manner. Another consequence of the shift to an internal focus of attention is an increased awareness of feared sensations.
Second, the model proposes that individuals use internally generated information to create an impression of how they appear to other people.
The information drawn upon includes feelings of anxiety and negative self-imagery. Negative images are common. Images usually come to mind from an observer perspective rather than a personal or field viewpoint, and so it is natural that the images are assumed to be an accurate representation of how the individual looks to other people. Third, the use of safety behaviours, which are motivated by the desire to prevent or minimise the consequences of feared outcomes such as sounding stupid or blushing , further maintains social anxiety and negative social beliefs.
Common safety behaviours in social anxiety include avoiding eye contact, preparing topics of conversation in advance, wearing lots of make-up, and agreeing with others. Safety behaviours are unhelpful for a number of reasons. They prevent the individual from discovering that the feared outcome was very unlikely to happen anyway. Safety behaviours can directly cause feared symptoms. For example, covering your cheeks to prevent blushing can make you hotter and cause flushing.
Safety behaviours can make one appear withdrawn and unfriendly. Behaviours such as avoiding eye contact or keeping conversations short can contaminate the social interaction and give the impression that one is not interested.
Finally, safety behaviours can draw attention to feared behaviours. For example, speaking very quietly may cause others to lean in and pay especially close attention in order to hear what is said.
Safety behaviours comprise a broad range of overt behaviours and mental operations. Some safety behaviours involve avoidance, such as speaking less and avoiding eye contact, whilst others are concerned with making a good impression, for example checking you are coming across well and preparing topics in advance. Whilst it is suggested that both groups of safety behaviours are unhelpful as they prevent disconfirmation of negative beliefs and increase anxiety, only avoidance behaviours contaminate the social situation by making the individual appear withdrawn and unfriendly.
Three studies have provided support for the distinction between avoidance and impression management safety behaviours.
Plasencia et al. In addition, correlational analyses indicated that both sets of safety behaviour appear to maintain social anxiety, but only the avoidance behaviours had a negative effect on other people.
In an earlier study, Hirsch et al. They found that items assessing avoidance behaviours were significantly correlated with negative ratings of the conversation, whilst items assessing impression management behaviours were not. Extending these correlational studies, a recent experimental study Gray and Clark submitted directly manipulated the use of safety behaviours during a conversation task.
The pattern of results was as expected, with use of both safety behaviour types increasing anxiety, but only avoidance behaviours resulting in a negative response from the conversation partner. Further unhelpful processes include anticipatory worry and post-event processing.
Before a social event, individuals with social anxiety will review what they think is going to happen in detail. Negative predictions will prevail and are associated with anxiety and a host of memories of past failures and negative self-images.
This worry is often enough to stop someone entering a social situation in the first place. If they do manage to go, they will be cued up to interpret social failings. Despite some brief relief on leaving a social situation, socially anxious individuals often describe a continued cycle of negative thoughts and distress.
Due to the inherently ambiguous nature of most social situations, it is rare that people receive an unquestionable seal of social approval. Post-mortems involve detailed revisiting of the previous event. However, because attention is trained internally during social events, and the focus is on negative thoughts, feelings and images, it is this that is reviewed in detail especially the most distressing moments , rather than the objective facts of the event.
As a result, the event will most likely be labelled a failure. Intense humiliation and shame commonly run alongside these ruminative thoughts. The post-mortem process can continue for days and sometimes weeks after an event. We suggest that the cognitive model of Clark and Wells has the potential to be a good fit for an adolescent population. For example, self-focused attention is emphasised in this model and it is a construct that has clear parallels with self-consciousness Stein which is heightened during adolescence.
Likewise, the concept of safety behaviours, which is emphasised in the model, may be pertinent to a teenage population. Avoidant safety behaviours may elicit particularly negative responses amongst adolescent peers, who as a group are especially sensitive to perceived peer rejection compared to children and adults see Kilford et al.
The rest of this review article is therefore concerned with two main questions. First, what evidence is there to support the application of the cognitive model of Clark and Wells to adolescents?
We stated from the outset that the intention of this paper was to outline the various reasons as to why there has been no solution so far to the disorder of social anxiety. In this part, we have lived to our promise by stating the diagnostic challenges that eventually lead to poor prescription of solutions towards solving the disorder.
Chances are that the solution might never be found. In our ensuing session, we make a few recommendations towards this end. Recommendations for future research Following the inability of various researchers to come up with a tangible solution towards solving social anxiety disorder, this paper has come up with some recommendations for any possible future research. First of all, we appreciate the fact that there have comparatively been no adequate studies regarding social anxiety disorders.
The absence of such studies leaves the affairs of the disorder in a precarious position as it has not been adequately diagnosed. We therefore recommend urgent and serious studies towards this end. Such studies must put into consideration the fact that the disorder is just an abnormal behavior; a personal and social values problem that can only be cured by social means, not medical prescriptions. The future researcher must consider the disorder as part of the personality of the individual, culture, society or a value problem and not a medical illness that requires bio-medical treatment or psycho-analytical diagnosis.
It should also not be diagnosed as mere shyness, as has been the case previously. The future researcher must base their research on personal values, social values, culture and personality of various individuals. We highly recommend that such research be comprehensive, detailed and prompt.
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