This in the fourth in a series of blog posts about CBT formulations. This blog will focus on CBT formulation for social anxiety.
1. What is social anxiety?
Social anxiety is a preoccupation with being evaluated negatively by others. In order to meet formal diagnostic criteria for a social anxiety diagnosis, this must cause social or occupational impairment, significant distress and be present for a minimum of 6 months. The fear must be out of proportion to the sociocultural context and threat present.
The adaptive side of social anxiety is that it can motivate individuals to perform well and may help to maintain socially appropriate behavior. This may motivate people to prepare for presentations or to express their opinions politely within conversation. However, this can become problematic if the preoccupation is to such an extent as to prevent the individual from doing socialising. Individuals may start to avoid social occasions for fear of being judged by others. This can include fear of being observed eating, fear of saying the wrong thing or fear of meeting new people. Individuals may overanalyze the comments or behaviours of others and interpret these as negative evaluations of their own behaviour. Their focus tends to be on analyzing the behaviour of others in an attempt to mind read if others view their actions as acceptable or unacceptable.
Some people may be more vulnerable than others to developing these difficulties.
2. Predisposing factors
Predisposing factors may include: biological vulnerabilities (behavioural inhibition and fear of negative evaluation), poorly defined social goals, socially anxious modeling by parents or a perception that others hold high social standards for them. For example, fearing that they will not live up to expectations if they had previously performed well.
Parenting styles may also play a part including overprotective parenting, which leads the child to avoid experiences they perceive as difficult, and lack confidence in their abilities to cope in these contexts. Anxious attachment styles may also lead to a difficulty interpreting the actions and intentions of others, being over cautious within social situations and perceiving cues of danger when these are not present.
3. Core beliefs
Core beliefs may include the belief that one is unable to perform in social situations and belief that others hold high social standards for them. They may believe that others will perceive them as weak or stupid, others will notice their anxiety symptoms. This includes the belief that others are monitoring their actions closely and will negatively evaluate them.
4. Precipitating factors
Precipitating factors include stress, unfamiliar social situations, loss of relationships, and anticipation of social embarrassment or lifecycle transitions.
5. Perpetuating factors
Perpetuating factors include dysfunctional thought patterns and safety behaviours. This includes: heightened focus on self including monitoring own behaviours such as conversation or gestures, negative self-perception, perceived poor social skills, low perceived motivation control and high estimated social cost.
Safety behaviours include avoiding unfamiliar situations or situations where a negative evaluation is possible and post-event rumination. Individuals may analyse their behaviour after an event in an attempt to check if they have acted socially appropriately.
6. Protective factors
Protective factors include: interests in engaging in activities, support from friends or family and a willingness to challenge their core beliefs.
7. Case example
Cara is meeting her partner’s friends for a dinner date. Cara has never met these particular friends previously but has heard a lot about them from her partner, Joel. Joel reassures Cara that these friends are looking forward to meeting her. Cara is familiar with the restaurant, as she has eaten there often. When Cara arrives to the restaurant she starts to feel anxious. Her hands start to shake as she approaches the table. Cara worries that Joel’s friends will notice this. Cara believes that her voice is noticeably shaky as she introduces herself. She excuses herself to go to the bathroom. Cara wonders if she should feign feeling unwell and go home as she does not want to embarrass herself and fears that Joel’s friends will dislike her and tell Joel this. She worries what they will think about her leaving abruptly to go to the bathroom.
This can be understood within a CBT formulation as follows:
Predisposing factor: Meeting new people (Joel’s friends). Attention is self-focused. Unclear if Cara has had parental modeling of anxiety or the type of attachment style she has.
Precipitating factor: The stress Cara experienced upon entering the restaurant led to her hands starting to shake. She became more anxious as a result. Cara’s attention is self-focused as she is vigilant to her experience of anxiety and shaky hands and voice.
Perpetuating factors: Cara is analyzing and monitoring her own physical sensations and behaviours. She then perceives others to have paid as much attention to these as her and to have given her a negative evaluation based on this. Cara has left the situation to avoid this discomfort, removing the possibility of challenging if these beliefs are true.
This cycle could be improved if Cara were to challenge some of her beliefs, including the belief that Joel’s friends are judging her. If she returns to the table she may find that she feels less anxious as the conversation continues and may find evidence that contradicts the belief that they dislike her. For example, they may tell her that they have had a nice time when the evening ends. If Cara returns to the table she will also be preventing herself from the safety behaviour of avoiding unfamiliar situations, which may give her confidence in future situations.
Protective factors: Cara is familiar with this restaurant.
The International Psychology Clinic
For more information about Cognitive Behavioural Therapy (CBT) for Social Anxiety, book a Consultation with one of our Therapists. We offer CBT, Counselling and Psychotherapy for Social Anxiety at our clinics in City of London, London Bridge, London Kensington, London Islington, London Marylebone, London Oxford Circus, Milan City Life, Milan Porta Romana, Rome San Giovanni, Rome Piazza Bologna, Rome Garbatella and Online worldwide.