Anxiety

The One-Dose Approach to Help for Social Anxiety Disorder

The newest approach to social anxiety disorder can help with just one dose.

Posted Apr 16, 2019

For people with social anxiety disorder (SAD), the idea of making a public appearance can be fraught with excessive worrying and self-doubt. After making such appearances, they continue to ruminate, or mull over, the mistakes they’re sure they made. Even if you don’t have social anxiety disorder, you may experience some of these reactions if you feel that you said the wrong thing that you believe inadvertently insulted someone who matters to you. Perhaps you were giving a toast at a work-related gathering, and no one laughed at your mild-mannered ribbing of your boss. Afterwards, you go over and over your flubbed attempt at humor and worry that this will come back to haunt you when your yearly evaluation time comes along. However, within a few days you are able to shrug it off and go about your everyday activities as if nothing happened. More importantly, no one at work seems to care about or even remember the entire incident.

Instead of being able to move past their public mistakes (or perceived mistakes), people with social anxiety disorder can’t stop thinking about what they did wrong. A newly published pilot study by Ryerson University’s (Canada) Bethany Shikatani and colleagues (2019) tested the idea that it is this difficulty in “post event processing,” or PEP, that forms one of the key features of social anxiety disorder. The authors define PEP as time during which people reflect on “actual or perceived inadequacies, mistakes, imperfections, and the like, and is ruminative in nature” (p. 84). To rid yourself of these harrowing PEP’s, you need to be able to redirect your thoughts to a more productive set of mental processes. The Canadian authors believe that people with SAD can put their negatively-tinged PEPs behind them with a relatively straightforward and quick evidence-based intervention.

One important caution in treating people with SAD, Shikatani and her collaborators note, is that some individuals with SAD may not at first appreciate the potential value of evidence-based treatments for helping them. Going into therapy, these skeptical individuals may not feel that the approach will be a good match for them. As stated by the authors, “patient attitudes should be considered when choosing evidence-based treatments” (p. 85). In studies of depression, people who had positive expectations about the method of treatment they were entering tended to improve more than people who were inclined toward a different approach. The Canadian investigation was intended to find out what would happen if they briefly exposed people with SAD to one of the evidence-based treatments for this disorder and then found out what they thought of it. They thought, further, that even this brief exposure could prove to be helpful in reducing some of that PEP-related rumination. 

Participants in the Ryerson University study were between 17 and 65 years old, and were recruited through advertisements, including online postings. Prior to the intervention, they completed an online measure of social phobia as well as a measure of their perceived confidence in public speaking. Once they passed the initial screening based on the scores on these online tests, they were interviewed in person to ensure that they fit the diagnostic criteria for SAD. The final sample of 58 adults were, on average, about 25 years old, and over 2/3 were women. Over half were single, most were college educated, and most were white (41%) or Asian (35%). None of them had been treated before with either cognitive-behavioral or mindfulness therapy.

The procedure to elicit PEP involved asking participants, individually, to stand in front of a video camera and give a 3-minute speech on one of 3 controversial topics (e.g. corporal punishment in schools). The experimenter told participants that they would subsequently be evaluated by a psychologist on their performance, who would rate their self-confidence and the clarity of their speech. Following this first experimental phase, participants were then randomly assigned to the mindfulness or cognitive-behavioral intervention, or to a no-treatment active control condition.

To teach mindfulness, the experimenter instructed participants first of all to focus on their breathing through a 3-minute guided exercise. Then, the experimenter encouraged participants to notice and accept their thoughts and emotions about their speech without judgment. This intervention took approximately 30 minutes to complete. For the cognitive-behavioral intervention, participants received education about the cognitive distortions involved in anxiety. The experimenter then assisted them in cognitive restructuring by having them identify and then and challenge their negative thoughts about the speech. This intervention lasted 40 minutes. For the active control condition, participants spent 20 minutes during which they were told to think about their negative thoughts without any instruction on how to manage those thoughts.

Immediately after the intervention, participants completed a measure in which they assessed their positive and negative thoughts about the speech as well as their overall SAD symptoms and thoughts about the feedback the experimenter provided. They came back one day later to complete a questionnaire assessing the acceptability and helpfulness of the intervention they had received (or not) in their experimental condition. This measure included a simple yes-no question to ascertain whether participants were interested in learning more about the strategy to which they had been exposed.

Compared to active controls, participants in the two actual intervention strategies rated their experiences as higher on both acceptability and helpfulness. The two strategies did not differ from each other on any of the key outcome variables. In line with Shikatani et al.'s predictions, the more credible the method seemed to participants, the more acceptable they found it to be. Those who liked the intervention reported that in the ensuing day, they were less distressed by ruminative thoughts about their recorded speeches. In other words, just that one session of either mindfulness or cognitive restructuring led participants to feel they had been helped in overcoming this particular experience of PEP.  

As the authors point out, the present study could not ascertain any long-term effects, nor could it evaluate possible contributing factors such as demographic variables, severity of symptoms, or personality. The research team also noted that the control condition was shorter than either of the two interventions. Another limitation was that the participants weren’t asked before they began the intervention to indicate what their treatment preferences might be. However, because participants were randomly assigned to condition, it would seem that these pre-treatment differences would be equally distributed across groups.

Importantly, Shikatani et al. believe that their findings support a trend emerging in the literature suggesting that individuals benefit the most when they are given a chance to make a choice among evidence-based treatments. This key step allows patients for their preferences to be incorporated into treatment. When you are seeking help for your medical symptoms, you like to be given a set of options. Why, assuming the treatments have equal effectiveness, should psychological treatment be any different?

To sum up, the complete elimination of symptoms from a longstanding psychological disorder are unlikely to occur in a single session. However, the current study suggests that jump-starting the process with that one dose of treatment can help people with SAD take that first step toward changing their mental set regarding their public behavior. By overcoming those ruminative PEP’s, they can move toward greater fulfillment in their relationships and their personal development.

References

Shikatani, B., Fredborg, B. K., Cassin, S. E., Kuo, J. R., & Antony, M. M. (2019). Acceptability and perceived helpfulness of single session mindfulness and cognitive restructuring strategies in individuals with social anxiety disorder: A pilot study. Canadian Journal of Behavioural Science / Revue Canadienne Des Sciences Du Comportement, 51(2), 83–89. doi:/10.1037/cbs0000121