Social Anxiety Disorder

Introduction

Social anxiety disorder is also known as social phobia. Socially anxious individual may focus on particular aspect of social interactions, such as speaking, eating, or writing in public, in which case they resemble simple phobias. The fear may be made worse by a lack of social skills or experience in social situations. Avoidance of social situations, intense nervousness and self-consciousness arise from a fear of being closely watched, judged and criticized by others. As a result of the fear, the person endures certain social situations in extreme distress or may avoid them altogether. In many cases, the person is aware that the fear is unreasonable, yet is unable to overcome it. They suffer from distorted thinking, including false beliefs about social situations and the negative opinions of others. Without treatment, social anxiety disorder can negatively interfere with the person’s normal daily routine, including school, work, social activities and relationships.

Definition: Social anxiety disorder is a chronic and debilitating fear of social interaction, where patients fear negative evaluation by others. Social anxiety disorder affects all aspects

of a sufferer’s life, by hindering the building and maintenance of social, personal, and work relationships, and commonly leads to isolation, depression, and even suicide (Lepine and  Pelissolo , 2000)

Diagnostic Criteria for Social Anxiety disorder:

According to the DSM-TR (2000) social anxiety disorder is defined in the following ways:

• A). A marked or persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.

• B). Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.

• C). The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.

• D). The feared social or performance situations are avoided or else are endured with intense anxiety or distress.

• E). The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

• F). In individuals under age 18 years, the duration is at least 6 months.

• G). The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g.,Panic Disorder with or without Agoraphobia, Separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or Schizoid Personality Disorder).

• H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of Stuttering, trembling in Parkinson’s disease, or exhibiting abnormal eating behavior in Anorexia Nervosa or Bulimia Nervosa.

Types of social anxiety disorder: There tend to be two sub-types of social anxiety disorder this are:

           a) generalized social anxiety disorder

          b) non-generalized social anxiety disorder.

a) Generalized social anxiety disorder: Generalized social anxiety is more disabling and involves a more diverse range of feared stimuli. Such as it is not confined to a few social situations; it impinges on all domains of social interaction [Stein and Chavira, 1998]. Those affected by it include some patients with avoidant personality disorder. This type of social anxiety is not easier to treat and it has a worse prognosis.

b) Non –generalized social anxiety disorder: The non-generalized form is confined to one or a few situations, of which the most common is public speaking, manifest as “stage-fright” [Stein and Chavira, 1998]. This is associated with avoidance of a limited range of performance situations or interactions (such as public speaking or eating in public), and this overlaps with performance anxiety in sexual dysfunction. Non-generalized social phobia is easier to treat, with a better prognosis.

Specific feature of social anxiety disorder:

i) Prevalence of social anxiety disorder: Social anxiety disorder (SAD) is among the most common of all psychiatric disorders. It presents with a lifetime prevalence rate of up to 16% in the general population and, like other anxiety disorders, it is more frequent in women. (Rosario, Hidalgo, Stewart, Barnett, Jonathan and Davidson, 2001). Social anxiety is third most prevalent psychiatric disorder, with onset often in childhood or early teens (Schneier, Johnson, Horning, Liebowitz, & Weissman, 1992).    In other study Kessler, McGonagle, Zhao, Nelson, Hughes and Eshleman et. al, (1994 )found that approximately 13.3 percent of the general population may meet criteria for social anxiety disorder at some point in their lifetime.

ii) Onset of social anxiety disorder: It is now widely observed that the onset of social anxiety disorder occurs typically during adolescence. In the community study by Schneier et al.[1992], two peaks of onset were dentified, in the 0–5 year age group (20 of 106 patients) and in the 11–15 year age group (25 of 106 patients). The mean age of onset in this study was 15.5 years and is comparable to that found in other studies: 15.2 years [Thyer et al.,1985] and 16.2 years [Turner et al., 1992].

iii) Course of social anxiety disorder: Social anxiety disorder is a chronic condition that rarely remits spontaneously [Juster and Heimberg, 1995]. During the prospective, non interventional Harvard Brown Anxiety Research Project, subjects with social anxiety disorder were regularly assessed using a Psychiatry Status Rating scale. Following one year of assessment, 39% of patients experienced minimal remission (fulfilling all diagnostic criteria and exhibiting disability without major impairment), 19% underwent partial remission, and only 7% of patients appeared to have undergone complete remission of symptoms [Reich et al., 1994]. These data confirm that, if left untreated, social anxiety disorder has considerable long-term morbidity, with a low probability of spontaneous remission.

iv) Economic consequences of social anxiety disorder

The individuals with social anxiety disorder are more likely to be unemployed and dependent on the state and their family for their financial support, than the general population. In the U.S. community study by Schneier et al. [1992], showed that people with social anxiety disorder were found to be a lower socioeconomic status than controls. In the other study Wittchen et al. [1999] have examined work productivity over 1 year in their cohort of patients, analyzing their results with respect to subtype and the existence of comorbidity. They found striking evidence that, overall, comorbid conditions worsen the effect of social anxiety disorder on work productivity. Also, the likelihood of employees being absent from work on more than 2 days per month was higher in those suffering from the generalized than the nongeneralized form of social anxiety disorder. It leads to increased use of medical services. In a French study of health service usage (by women) over 1 year [Lépine and Lellouch,1995], significantly more women with social anxiety disorder (8%) visited a psychotherapist, compared with 2% of women without the disorder. Furthermore, almost twice as many subjects with social anxiety disorder (24%) were hospitalized compared with those without the condition (13%); this was also observed when the data were adjusted for the presence of depression.

V) Quality-of-life issues in social anxiety disorder: Social interaction of socially anxious individual affects all aspects of life and social anxiety disorder hampers work, social, and personal relationships. The affected are more likely to be unemployed, live alone, and be unmarried or divorced. These are resulting from social anxiety disorder and have a great impact on a person’s quality of life. When patients with social anxiety disorder (n = 239) and normal controls (n = 232) were asked to complete the Short Form 36 (SF36) health survey questionnaire [Jenkinson et al., 1993], marked differences in health and well-being factors were evident between the two groups (J.P. Lépine et al., unpublished data). Overall, quality of life of the subjects with social anxiety disorders was more limited.

Etiology of social anxiety disorder

The etiology of social anxiety disorder is not fully understood, but the likelihood of developing this disorder involves a combination of several factors, such as: environmental, biological, and psychological factors.

Biological: why do some people acquire unrealistic fears when others do not, given similar opportunities for learning? Perhaps those who are adversely affected by stress have a biological malfunction that somehow predisposes them to develop a phobia following a particular stressful event. Research in two areas seems promising: the automatic nervous system and genetic factors.

a) Autonomic nervous System: people with social anxiety disorder often fear they will blush or sweat heavily in public. Since both sweating and blushing are controlled by the autonomic nervous system, over activity of the autonomic nervous system becomes a candidate for a diathesis. A recent study assessed blushing during three different stress tasks in three groups of people: those with social anxious who reported that they blush a lot, those with social anxious who did not reported did not reported excessive blushing and controls. Participants with social anxious self reported more blushing during each of the three stress tests, but they actually blushed more than the controls during only one of the three tests. The people with social anxious who had earlier reported blushing did not actually blush more than the people with social anxiety who did not report blushing (Gerlach et al., 2001). Therefore, while automatic over activity is some of relevance to social anxiety, the fear of the consequences of automatic activity may be more important.

b) Genetic factors: Family studies indicate a genetic predisposition for the development of social anxiety disorder.  According to Millon, Blaney, and Davis (1999), the estimated heritability for social phobia ranges from 12 to 60% depending on the particular study.  The average heritability based on several different studies is 37%.  These data show heritability plays a role in the development of social phobia.

Twin studies and family studies also suggested the role of genetic factor in the development of social anxiety disorder.

  i) Twin Studies As cited in Zuckerman (1999), Kender et al. (1992) found a heritability of 30% for social phobia.   Kender et al. also found a concordance rate of 24.4% for monozygotic (identical) twins and 15.3% for dizygotic (fraternal) twins.  A concordance rate is the percentage of time that both twins have the disorder.  These data show that there seems to be a genetic component involved in the acquisition of social phobia.

ii) Family Studies:  Family studies show higher rates of social phobia in relatives of patients with social phobia than in relatives of normal control subjects.  Zuckerman (1999) reported that Fryer et al. (1995) found the disorder in 16% of relatives of social phobia patients compared with 5% of control relatives.  These data suggest a significant heritability of social phobia.  In other words, individuals with family members that have social phobia are more likely to develop the disorder than individuals with family members who do not have the disorder.

c) Abnormalities in amygdala:  The amygdala is a structure in the limbic system that is implicated in the fear and startle response.  Persons with social anxiety disorder might be more susceptible to fear evoking stimuli because of abnormalities in the amygdala.  As cited in Velting and Albano (2001), Pine (1999) found that individuals with social phobia have hypersensitive amygdala.

2) Psychoanalytic Theories:  Freud argued that phobias help to contain threatening impulses and to keep them out of awareness by motivating a person to keep away from the feared situation (Nevid, Rathus, & Greene, 1991).  In his theory, unconscious motives are at work, and phobias lead to the avoidance of situations in which impulsive behavior could occur.  Based on this theory, socially phobic individuals avoid social situations because of unconscious drives that protect them from having to overcome any impulsivity produced by the situation.  This type of avoidance is an unconscious, but protective, avoidance.  An example of repressed, unconscious impulsivity would be the desire to derogate others in social situations.  Freud believed that we repress socially unacceptable ideas; therefore, a person with social phobia may have unconscious motives keeping them away from social situations so that this socially unacceptable, impulsive behavior can be avoided.  Because of the difficulty in directly observing unconscious motives, there is little empirical support for this etiological mode.

3) Cognitive behavioral causes: Many psychological theories focus on learning or conditioning as the way in which social anxiety are acquired. Several types of learning or conditioning may involve:

a)  Avoidance conditioning: the main behavioral account of phobias is that such reaction is learned avoidance response. For example, if an individual has a negative experience in a social situation, such as giving an oral presentation, he or she learns that those kinds of situations should be avoided.  Eventually, this type of avoidance may generalize to other situations so that the individual will begin to avoid any social situation in which embarrassment or humiliation may occur Historically, Watson and Rayner’s (1920) demonstration of the apparent conditioning of fear or phobia in Little Albert is considered the model of how a phobia may be acquired. Zuckerman (1999), Hoffman, Ehlers, and Roth (1995) found that 89% of a group of individuals with social phobia involving fear of public speaking recalled a negative experience associated with their fear.

b) Negative Evaluation: the person with social anxiety disorder evaluated themselves negatively which causes their social anxiety disorder. Zuckerman (1999), Rapee and Lim (1992) found that social phobic individuals show a sense of lack of control, biased expectations, and negative evaluations that could stem from early developmental experiences. This research finding suggested that person with social anxiety disorder may perceive their performance more negatively than others. Even when others perceive their performance as adequate, socially anxious individual might have negatively evaluations of themselves.

c) Irrational Beliefs:  Individuals with social anxiety disorder typically hold more irrational, negative beliefs about themselves and others than those without phobias.  For social anxiety disorder, these irrational beliefs are typically based upon the need for approval or acceptance.  They may view themselves as unacceptable and inferior to other people.  As cited in Turk, Heimberg, and Hope (2001), Stopa and Clark (1993) found that individuals with social phobia have mostly negative, self-derogatory automatic thoughts.   In this study, socially anxious individuals had negative, self-critical thoughts.  These kinds of irrational beliefs about one’s performance, abilities, or inferiority drastically affect their perceptions about their performance in social situations. .

d) Perceived Danger:  Socially individuals may also have cognitions that cause them to perceive danger in situations that others would consider safe (Nevid, Rathus, & Greene, 1991).  For example, persons with social anxiety may dwell on their fear of embarrassing themselves or being rejected in situations where most people would not have these irrational and threatening cognitions.

e) Modeling:  to learn to fear something as a result of an unpleasant experience with it, fear may be learned through imitating the reactions of others. Some fear is learned by modeling. A wide range of behavior including emotional responses may be learned by witnessing a model. The learning of fear by observing others is generally referred to as vicarious learning. In one study, Bandura and Rosenthal (1966) arranged for participants to watch another person, the model in an aversive conditioning situation. The model was hooked up to an impressive looking array of electrical apparatuses. On hearing a buzzer, the model withdrew his hand rapidly from the arm of the chair and feigned pain. The physiological responses of the participants witnessing this behavior were recorded. After the participant had watched the model suffer a number of times, they showed an increased frequency of emotional responses when the buzzer sounded. The participants began to react emotionally responses when the buzzer sounded. The participants began to react emotionally to a harmless stimulus even though they had had no direct contact with a noxious event.

f) Social skill deficit in social anxiety disorder: The behavior model of social anxiety considers inappropriate behavior or a lack of social skills to be the cause of social anxiety. According to this view, the individual has not learned how to behave so that he or she does not feel comfortable with others. Support of the model comes from findings that socially anxious people are indeed rated as being low in social skill( Twentymsn & McFall, 1975) and that the timing and placement of their response in social interaction , such as saying “thank you” at the right time , are impaired (Fischetti, Curran, & Wessberg, 1977).

g) Cognitive model of social anxiety disorder: The causes of social anxiety disorder also discussed by the cognitive model of social anxiety disorder. In this model the role of negative self-appraisal process in social anxiety is explained. It was developed by Clark and wells (1995). It focuses on those factors that maintain social anxiety. It also attempts to explain the reason why the individual with social anxiety fail to benefit from the naturalistic exposure. It explained that social anxiety is seen a resulting from the problematic belief from oneself and one’s social world, which lead individuals to interpret social situation in the excessive negative fashion.  These negative interpretations also known as feared prediction or social fear beliefs are then maintained by the following processes which are discussed in the following:

a) Processing in Social Situations

On the basis of early experience, patients with social anxiety disorder develop a series of assumptions about themselves and their social world. The assumptions can be divided into the following three categories:

• i)Excessively high standards for social performance, e.g., “I must not show any signs of weakness”, “I must always sound intelligent and fluent”, “I should only speak when other people pause”, “I should always have something interesting to say”.

• ii) Conditional beliefs concerning the consequences of performing in a certain way, e.g., “If I disagree with someone, they will think I am stupid”, “If my hands shake/I blush/or show other signs of anxiety, people will think I am incompetent/odd/stupid”, “If I am quiet, people will think I am boring”, “If people get to know me, they won’t like me”.

• iii) Unconditional negative beliefs about the self, e.g., “I’m odd/different”, “I’m unlikeable/unacceptable”, “I’m boring”, “I’m stupid”, “I’m different”.

Such assumptions lead individuals to appraise relevant social situations as dangerous, to predict that they will fail to achieve their desired level of performance (e.g., “I’ll shake, I’ll make a fool of myself”) and to interpret often ambiguous social cues as signs of negative evaluation by others. Once a social situation is appraised in this way, the social anxious becomes anxious. Several interlinked vicious circles then maintain the individual’s distress and prevent disconfirmation of the negative beliefs and appraisals.

b) Processing of the Self as a Social Object

When socially anxious individuals believe they are in danger of negative evaluation by others, they shift their attention to detailed monitoring and observation of themselves. They then use the internal information made accessible by self-monitoring to infer how they appear to other people and what other people are thinking about them. In this way they become attentive in a closed system in which most of their evidence for their fears is self-generated and disconfirmatory evidence (such as other people’s responses) becomes inaccessible or is ignored.

c) Safety Behaviours

People with social anxiety attempt to prevent their fear by using avoidance or safety behaviors. Safety behaviours are overt or covert behaviors or strategies that are engaged in with the goal of preventing the individual’s feared outcomes from occurring (Salkovskis, 1991). Socially anxious individual engage in safety behavior in attempts to reduce their anxiety, these behavior often have the paradoxical effect of perpetuating their negative prediction about how other people will perceive them and thus, in turn maintenance their social anxiety. Clark and Wells agree that safety behaviours operate in this fashion in social anxiety disorder and highlight several additional interesting features of socially anxious-related safety behaviours, which are as follows:

i)                    many safety-seeking acts are internal mental processes.

ii)                  the socially anxious individual  to engage in a large number of different safety behaviours while in a feared situation. This large number of safety behaviours was used to prevent each feared outcome.

iii)                These behaviours can create some of the symptoms that the individual fear. For example, trying to hide underarm sweating by wearing a jacket produces more sweating.

iv)                most safety behaviours have the consequence of increasing self focused attention and self-monitoring, thus further enhancing the one’s negative self-image and reducing attention to others’ behaviour.

v)                  some safety behaviours can draw other people’s attention to the patient. For example, a secretary who covered her face with her arms whenever she felt she was blushing discovered that colleagues in her office were considerably more likely to look at her when she did this than when she simply blushed.

vi)  some safety behaviours influence other people in a way which partly confirms the social phobic’s fears. For example, social phobics’ tendency to  continually monitor what they have said and how they think they have been received often makes them appear distant and preoccupied.

d) Somatic and Cognitive Symptoms

Social anxious people concerned about their somatic and cognitive symptoms of anxiety. They thought that this symptoms could be observed by others (e.g., sweating, feeling hot in the face, tremor, mental blanks) and interpret them as signs of failure to meet their desired standards of social performance. Because of the perceived significance of arousal symptoms, patients are often hypervigilant for such symptoms, which tends to increase the subjective intensity of the somatic and cognitive symptoms. The use of safety behaviours by the client could be enhanced this symptom.

e) Processing of External Social Cues                             

The model by Clark and Wells places particular emphasis on self-focused attention and the use of internal distorted information. Beside the self-focus attention, it is thought that social anxiety is associated with reduced processing of external social cues. However, Clark and Wells also suggest that socially anxious individual processing of the external social situation is reduced and likely to be biased in a negative direction. In particular, they may be more likely to notice and remember responses from others that they interpret as signs of disapproval.

f) Processing before and after a Social Situation: Social anxiety disorder have also maintained by the processing before and after a social situation. Many socially anxious experience considerable anxiety when anticipating a social event. Prior to the event they review in detail what they think might happen. As they start to think about the event, they become anxious and their thoughts tend to be dominated by recollections of past failures, by negative images of themselves during the event, and by other predictions of poor performance and rejection. In anticipation of problematic situation socially anxious tends to worry about the situation, which serves to increase anxiety.  On leaving the situation the exposure of the negative aspect of the encounter does not end. After the social situation the interaction is reviewed in detail. During this review, the patient’s anxious feelings and negative self-perception are increase. The unfortunate consequence of this is that the patient’s review is likely to be dominated by his or her negative self perception and the interaction is likely to be seen as much more negative as it really was. This post-event processing contributes to an overemphasis on negative aspects of the encounter.

4) Technology’s Influence on Social anxiety disorder:  Although evidence suggests that social anxiety disorder has causes by psychological factors, some research has found that technology may reduce social interaction which causes social anxiety disorder.  In a study Kraut et al. (1998) followed 169 people during their first 2 years of internet usage.  They found evidence to suggest that technology and automated services, such as gasoline and bank teller machines, are reducing the need to interact with others.  These advances in technology could possibly cause people to be more isolated and socially inhibited. In their study, they found that that internet usage decreased social involvement and increased depression and loneliness.  With more advances in technology, individuals have less need to interact with others in settings such as the gas station and the bank.  Social interaction has even decreased in academic settings because of the growing popularity of online degree programs.

Management of social anxiety disorder

The term management means carrying out of functions of planning, organizing and directing any enterprise. In other sense, management indicates treatment or taking a problem in a manageable position. Management for social anxiety disorder (SAD) depends on the severity of the client’s emotional and physical symptoms and how well he or she functions daily. The length of treatment also varies. Some people may respond well to initial treatment and not require anything further, while others may require some form of support throughout their lives. The following techniques are used for social anxiety disorder management.

A) Pharmacological management:   Several pharmacologic therapies have proven effective for reducing the symptoms and functional limitations experienced by the individual with social anxiety disorder. The following drug treatments have a role in the treatment of this disorder.

a) Selective serotonin reuptake inhibitors (SSRIs):  This group of medications is considered the first line of pharmacologic treatment for social anxiety disorder.  The first multicenter, randomized, double- blind study of an SSRI found that SSRIs were effective and well-tolerated in reducing the symptoms and avoidance that are characteristic of social anxiety disorder.

The trial lasted 12 weeks; the dosage of paroxetine ranged from 20 to 50 mg/day (.Fones,  Manfro, and Pollack,  1998) (stein et. al., 1998) Generally well tolerated, SSRIs have produced acute improvement in 50% to 75% of patients. (Bruce and Saeed, 1999 )

b)Monoamine oxidase inhibitors (MAOIs):  Before the advent of SSRIs, MAOIs were considered to be the first-line drug treatment for social anxiety disorder. However, problems with tolerability, including drug interactions, limit their use.

c)Benzodiazepines;  Limited data support the efficacy of highpotency benzodiazepines, specifically clonazepam (Klonopin) and alprazolam (Xanax). Most of the patient with social anxiety disorder experience unwanted side effects such as sedation and dulled thinking.long-term use may lead to physical dependence, including withdrawal symptoms when the drug is discontinued. In addition, benzodiazepines interact strongly with alcohol, and comorbid alcohol dependence is known to be common in patients with social anxiety.( Scott and  Heimberg,  2000) (Davison,1999)

d)Beta-blockers:  Although beta-blockers may be used to treat specific performance-related anxiety, controlled studies have not supported their efficacy in generalized social anxiety disorder.(Davison,1999; .Fones,  Manfro, and Pollack,  1998).

e)Other medications: Some medications showing early promise include venlafaxine (Effexor), nefazodone (Serzone), and gabapentin (Neurontin).

B) Psychological management: Psychological management is defined as any psychotherapeutic procedure design to cure or to lessen the severity of a disease or other abnormal condition. The goal of providing psychological management is to bring a shift from undesirable condition to a desirable condition that is related to the specific psychological problem or disorder. The common psychological treatments used for social anxiety disorder are reported below:

1) Psychodynamic therapy: Psychodynamic therapy was developed by Freud. Psychoanalytic treatment of social anxiety disorder attempts to uncover the repressed conflicts that are assumed to underlie the extreme fear and avoidance characteristic of these disorders. Free association and dream analysis technique were used to uncover repressed conflict. During the free association the analyst listen carefully what the person mention in connection with social anxiety. The analyst also attempts to discover clues to the repressed origin of the phobia in the manifest content of the dream . In the ending session of the psychoanalysis the analyst must encourage the client with social anxiety disorder to engage in those activities which he avoided in the past.

2) Cognitive behaviour therapy: Cognitive behaviour therapy (CBT) is one kind of psychotherapies based on scientific psychological principles. CBT is based on the concept that emotions and behaviors result (primarily, though not exclusively) from cognitive processes; and that it is possible for human beings to modify such processes to achieve different ways of feeling and behaving (Froggatt, W.; 2006). In CBT, clients and therapists work together, to identify and   challenge negative thought and beliefs, which can assist a person to reduce distress and enhance their ability to cope in everyday life situations. Recent research into the treatment of social anxiety has concentrated on the development of cognitive behavioral treatments with promising results (Hirsh  and Mcmanus, 2007). Clark Wells and their colleagues have developed and refined a 14 session cognitive behavioral treatment for social anxiety disorder that has been arisen from Clark and Wells’ cognitive model of social anxiety disorder. For individual treatment of social anxiety disorder the following cognitive behavioral specific intervention are used. This are include;

a) Psychoeducation: Psychoeducation used to socialize the client about the cognitive model of social anxiety disorder and cognitive behavior therapy. It also helps to understand the nature of client’s social anxiety disorder and it’s maintaining factors.  It also used to give scientific information about safety behaviours, self focus attention and others necessary area.

b) Self-focus attention and safety behaviours experiment: self focus attention and the use of safety behaviors contribute to the maintenance of social anxiety. To explore the effect of safety behaviour and self-focused attention, the client is asked to take part in two social interactions during the session. The client and the therapist collaboratively identified the situation that would elicit a moderate level of anxiety for the client. Once a relevant situation  has been identified, the therapist elicited the client’s feared predictions by asking what he or she is worried could go wrong in the situation what is the absolute worst that could be happen, and what it would mean if those things did happen. The client is asked to rate his or her feared predictions on a 0-100 scale. The therapist then identified the client safety behaviours by asking what he or she does to prevent the fear predictions from happening, or from being noticed by others or from being evaluated negatively by others.

Once all of the safety behaviours have been identified the client is asked to engage in the social situation for a few minutes in this first interaction, the client is asked to do his or her safety behaviours and monitor how he is coming across the as much as possible. To facilitated comparison of the two interaction the client is asked to rate the extent to which he or she engaged in safety behaviours, how anxious he or she felt, or how anxious he or she think he or she looked and the extent to which the feared catastrophes occurred ( from 0 nor at all to 100 totally). The client is also asked to rate how well he or she performed (from 0 not at all well to 100 extremely well). The client also rates the extent to which his or her attention is focused externally (on the situation or people) or internally (i.e. on him or herself). This can be assessing on a -3 to +3 scale (where -3 is totally self focused and +3 is totally externally focused).

After making the ratings, the client is asked to repeat the interaction without engaged safety behaviours and to focus his or her attention externally. It is often necessary to practice dropping safety behaviors and self focus attention with the therapist before trying to do it during the social interaction. Once they had practice dropping safety behaviors and self focus attention, client then engaged in a second social interaction and make rating as before. Sometimes clients believed that the second interaction is better because they had met the person before. If this happen they asked to engaged in a third interaction, this time using their safety behaviour again and make ratings as before, so that they can see that it is not merely a practice effect. Another problem that may also arise is that sometimes clients are unable to drop their safety behaviors in the second interaction. If this happen the client is asked to engage in a third interaction, and this time do their safety behaviours as much as possible. Rating from the third interaction (where they used their safety behaviour and self focus a lot) can then compare with the second interaction (where they used their safety and self-focus rarely less).This will enable client to see the effect of using self focus and safety behaviour excessively. Completing the final interaction and rating taking, the client and therapist collaboratively reviewed the client’s rating of different interaction. This can lead to useful insights. Client learn that they feel less anxious and less fear prediction happen, when they do not use safety behaviors and self focus attention. From the exercise the client conclude that they do not need to use safety behaviours to prevent their fear predictions from happening and that they feel less anxious and come across better when they focusing externally and not using safety behaviours. These conclusion can be further developed  by seeing the feed back with the conversation partner.

c) Behavioral experiment: the purpose of the behaviour experiment is to test the validity of client’s social fear. This will involve client going into a range of social situations that they find anxiety provoking to find out their fear catastrophes do indeed occur. To discover whether their fear catastrophes happening client will need to focus on the social situation and refrain from using safety behaviour. Client asked to using a behaviour experiment record sheet ( figure-1.a). This behaviours record sheet provides a structure for client to learn to set up behaviour experiment themselves in order to systematically test out their catastrophes in social situation.

In the record sheet of the behaviour experiment the date is entered in the first column and the brief situation is entered in the second column. The client’s prediction about what he or she think will happen in the social situation in the third column. The next column specifies the experiment column. This is where the clients summaries what they plan to do in the social situation in order to test out their fear prediction. In the next column, clients rate whether each of the feared predictions identified in column 3 did actually happen, from 0 to 100 (where 0 not at all and 100 totally). In the final column clients summaries what they have learn from the experiment, including any conclusion drawn from the comparison of comparison of predicted and actual outcomes.

d) Survey: it is useful for the client to learn that experiencing some amount of social anxiety is the norm rather than the expectation, and to learn that even if they did exhibit their feared symptoms or perform poorly, that people would not necessarily interpret this as critically as they fear.  This can be done through a survey where other people are asked a series of question by the client for assessing what they think about a person exhibiting a given symptoms of anxiety. To do this, the client and therapist construct a survey to address client’s idiosyncratic concerns about their fear symptom. The question of the survey like ‘Have you ever blushed?’ ‘Do you ever notice other people blush?’ ‘What did you make of that?’ ‘Did you think they were weak?’ ‘If so how much (0-100)?’ ‘Do you remember them blushing a day/month/year later?’  By conducting the survey the client learn that most people experiencing anxiety, and that the majority people do not judge other critically or reject them for showing symptoms of anxiety or perform poorly.

e) Looking at numbers: this is another useful technique for the client is calculating the number of times the fear outcome has actually occurred when clients thought that they were showing anxiety symptoms. This can be calculate bys asking the client how many times a day, he or she has had the thought that he or she is showing his or her feared symptom ( for example if this was three)then multiple by it 365 days (i.e. 1095) and then by the number of years that she or he has had their fear (if 10 years, which means 1,950 times she or he believed the blush was evident). Then the client is asked to think of the number of times someone has commented on the symptom, or seemed to notice it. Typically this will be very  rarely and then the client can thus begin to see how the symptom is either nor noticed or not deemed to be important most of the time they thought it has been present. The client then asked how many times the other person’s reaction was negative. For example it was commented on only twice in ten years and both times it was not negative. So his or her feared outcome occurred 0 times in the 10,950 times he or she had believed that she blushed.

f) Anticipatory processing: Anticipatory processing is another cognitive process that need to focused in the therapy. In addition, people with social anxiety disorder often suffer “anticipatory” anxiety — the fear of a situation before it even happens — for days or weeks before the event. Client will have learned from the behavioral experiments that things usually do not go as badly as they anticipate, demonstrate that they overestimate danger prior to social event.   Asking the client to list its costs and benefits enables them to conclude that it is nor helpful.

g) Post event processing: Focusing of poor performance, socially anxious people think about how they come across the situation after leaving the anxiety- provoking situation. The post event processing does not help and make them feel worse. To address this, clients should list the advantage and disadvantage of the post event processing. This is helping  the client to understand the worse of the post event processing. Clients are then encouraged not to do post event processing.

h) Social skill training:  Learning social skills can help the people with socially anxious who may not know what to do or say in social situations. Some behavior therapists encourage patients to role-play or rehearse interpersonal encounters in the consulting room or in small therapy groups. Group therapy may also be helpful for individuals who need to develop social skills and overcome their anxiety in social situations.  In a group setting, the person with social phobia will be able to interact directly with other individuals who can also give feedback about the actual performance of the individual to help challenge some of their negative evaluations.

i) Blueprint: Blueprint is a few pages that detail  the client’s understanding of why social anxiety developed and what maintain it, information what is learned from behavioral experiment, thought challenge and others intervention. In the end of therapy it is useful to get client to reflect what they learn about their social  anxiety and generate a summary in the form of a blueprint. It should include a plan of what the client needs to do in the nest years to address the social anxiety disorder further and what to do if he or she had relapse.

Rational of the present research:

In Bangladesh, 16.05% populations have been suffering from various psychiatric problems (National Mental Health Survey, 2003- 2005); Social anxiety is one of the psychiatric problems. Social anxiety disorder affected various aspect of the life of suffers and it significantly interfere occupational, social, personal, academic and others important area of functioning. The affected people are more likely to unemployed, live alone or divorced. Most of them were dependent on the state or their family for their financial support. These all factors have a great impact of the quality of life of the affected individual. Overall the quality of life of the individual with social anxiety disorder was more limited. Without treatment the condition will be worsen day by day. So it is a big need to treated social anxiety disorder. On the other hand, the field of clinical psychology involves research, teaching, and services relevant to the application of principles, methods, and procedures for understanding, predicting, and alleviating intellectual, emotional, psychological, social, and behavioral maladjustment, disability and discomfort, applied to a wide range of client populations.( J. H. Resnick, 1991). Clinical psychology is still a new mental health profession in Bangladesh; clinical psychologists need to examine the outcome of psychological intervention. Psychological interventions, especially CBT, in the treatment of social anxiety have flourished considerably in recent decades. Clark and Wells and their colleagues (2006) have demonstrated that cognitive therapy is effective for the treatment of social anxiety. No study has yet been done in Bangladesh to examine the effectiveness of CBT for social anxiety. So the researchers need to study the effectiveness of CBT for social anxiety disorder.

It is anticipated that the research will create a new attitude among clinical psychologist, psychiatrist, psychiatric social worker, psychotherapist, psychologist and different health care professional to manage social anxiety disorder patient and they will be able to recognize the importance of cognitive therapy management for social anxiety disorder. The study will help to grow awareness among them about the effectiveness of CBT for social anxiety.  It will help the practicing and trainee clinical psychologist and other mental health professionals to provide guideline how to manage the socially anxious people in Bangladesh. It will also helps to created further research field in the glove.

Objective:

The main objective of the study will be to see the efficacy of cognitive behavior therapy for social anxiety.

The other objectives are given below:

i)                    To assess the psychological problem faced by the socially anxious people

ii)                  to find out whether psychological management can bring any positive change of socially anxious people.