ADAPTATION OF IPT FOR SOCIAL ANXIETY DISORDER (SAD)
Excessive social anxiety can be a distressing and disabling problem. Social anxiety disorder (SAD; also called social phobia) is defined as excessive fear of one or more social situations due to concern about scrutiny or potential embarrassment, which leads to significant distress or impairment in functioning (APA, 1994). Epidemiological studies indicate that up to 13% of the population will experience SAD in their lifetimes (Kessler et al., 2005; Wacker et al., 1992). The most commonly feared social situation is public speaking, but fears include a range of routine daily situations. Up to 80% to 90% of people who seek treatment for SAD have generalized SAD, defined as excessive fear in most social situations (Liebowitz et al., 1992). SAD typically begins by adolescence (Magee et al., 1996). Left untreated, its course is generally chronic (Bruce et al., 2005; Reich et al., 1994), with highest prevalence in early adulthood (Wittchen & Fehm, 2003). SAD is associated with significant impairment in work and social functioning (Schneier et al., 1994), impaired quality of life (Simon et al., 2002), and considerable economic cost to society (Lipsitz & Schneier, 2000). SAD often co-occurs with other psychiatric disorders, particularly other anxiety, mood, and substance use disorders (Magee et al., 1996). Because SAD onset typically precedes other disorders (Magee et al., 1996; Angst, 1993), it may be a risk factor for later psychopathology.
Predominant psychological models of SAD emphasize a complex interplay of cognitive and behavioral factors that maintain SAD. The two best-studied formulations (Clark & Wells, 1995; Rapee & Heimberg, 1997) highlight a range of cognitive features, including stable core beliefs, attentional and interpretation biases, overestimation of threat, negative self-perception, and internally focused attention. These cognitive factors interact with actual avoidance or subtle avoidance maneuvers, known as safety behaviors (Wells et al., 1995), which are meant to minimize the risk of adverse outcomes. This cognitive-behavioral constellation precludes direct processing of potentially corrective feedback. This model forms the foundation of efficacious cognitive-behavioral therapy (CBT) treatments for SAD (Clark et al., 2006; Heimberg et al., 1998); some evidence indicates that cognitive changes mediate these benefits (Hofmann, 2004).
Interpersonal theory of SAD (Alden & Taylor, 2004; Lipsitz & Markowitz, 1997) implicates self-perpetuating cycles of social interactions as contributing, reciprocally and over time, to increasing social anxiety and avoidance (Alden & Taylor, 2004). Interpersonal theory focuses on real rather than imagined or misperceived interpersonal consequences of anxious behaviors (Alden & Wallace, 1995). Research suggests that there is often a “kernel of truth” in perceptions of adverse and negative reactions (Spence et al., 1999), which creates a negative interactional pattern always involving at least two players. Blote and Westenberg (2007), for example, assessed adolescents’ perceptions of negative class reactions during a public speaking task. They found that socially anxious adolescents’ perceptions of negative class treatment were not exaggerated but rather consistent with ratings of other students. This focus on interactional patterns rather than behavior per se or internal processing of experience suggests that there is a place for a more interactional therapeutic strategy (e.g., assertively challenging critical reactions rather than re-interpreting them), such as that IPT espouses.
Second, the interpersonal approach sees important interpersonal relationships and the individual’s primary role in society as providing an important context for development and maintenance of psychopathology (Klerman et al., 1984; Sullivan, 1953). In SAD, social anxiety per se is, and its immediate consequences are focused mostly on strangers and acquaintances, less so on close friends and family. However, a growing body of research indicates that SAD is associated with a range of difficulties in close relationships (Alden & Taylor, 2004; Davila & Beck, 2002; Neal & Edelmann, 2003). Interpersonal difficulties include fewer close friends in adolescence (Beidel et al., 1999), fewer heterosexual relationships in college (Dodge et al., 1987), greater likelihood of remaining unmarried (Schneier et al., 1992), more problems with intimacy in romantic relationships (Wenzel, 2002), and relationships characterized by dependence and unassertiveness (Davila & Beck, 2002; Stangier et al., 2006). Some of these interpersonal difficulties emerge in childhood and adolescence in the form of peer neglect and rejection as well as harassment, teasing, and bullying (Beidel et al., 1999; Crick et al., 1993; LaGreca & Lopez, 1998; Storch & Masia- Warner, 2004). Beidel et al. (1999) found that children and adolescents with SAD experienced distress due to lack of friendships. The interpersonal model sees these difficulties not merely as sequelae of social anxiety and avoidance but as interacting reciprocally to help develop and maintain this disorder. Interactional patterns that characterize SAD are understood within the context of broader difficulties of human attachment (Ainsworth & Bowlby, 1991; Bowlby, 1973).
The role of close relationships in SAD is supported by additional lines of research. Cuming and Rapee (2010) found that for women, social anxiety was associated with decreased self-exposure even within intimate relationships. When Grewen et al. (2003) randomized couples to “warm contact” or no contact immediately prior to a recorded speech task, individuals receiving warm contact demonstrated lower blood pressure and lower heart rate compared to the low-contact group. This suggests that features of a close relationship may moderate the effects of feared social situations for the socially anxious. Finally, Russel et al. (2011) recently found that emotionally secure situations led to increased pro-social behavior for the socially anxious, suggesting that engaging aspects of the real social situation can help the individual overcome social anxiety and avoidance.