**2. Intra- and interpersonal aspects of social anxiety disorders**

On a theoretical and therapeutic level, SAD can be described and treated with a focus on individually impaired internal processes and modes of behavior. This includes the amplitude of emotional life (e.g., unease, nervousness, panic) and somatic experiences (e.g., sweating and hot flashes) in specific social situations. Core cognitive processes refer to dysfunctional beliefs and self-focused attention, limiting the perception of external stimuli. It also includes modes of behavior depending on how strongly the patient avoids the feared situations. On the other hand, SAD can also be described and treated with the focus on the affected social system. This includes problems while interacting with others (e.g., arguing) and one's overall experience within the social system (e.g., belonging, cohesion, flexibility, accord). The convergence of both foci makes SAD an intra- and interpersonal disorder: symptoms of fear arise when the affected person experiences that he or she may attract critical attention from others; these symptoms in turn constrain the person's ability to successfully build and maintain social relationships [14].

**Intrapersonal models.** Cognitive behavioral models on SAD are largely intrapersonal models. There is a common ground between the models of the first generation. *Beck, Emery, and Greenberg* [15] explain SAD by distorted cognitive schemata (e.g., "No matter what I do, I'll make a mistake!") resulting from negative interaction with significant others in early childhood to youth. Once generated, these schemata are activated in stressful and challenging situations in the kind of unconditional negative core beliefs (e.g., "I am inept!") and conditional beliefs (e.g., "If I show myself, I'll behave stupid!"). Successful treatment of SAD should change these problematic negative cognitive schemata. There however still is the question why some schemata do not change though people are exposed to lots of positive situations. *Clark and Wells* added characteristics of information processing to explain the maintenance of SAD: (1) self-focused attention, (2) safety and/or avoidance behavior, and (3) fearful anticipation before an event and negative rumination after it. *Rapee and Heimberg* [16] emphasize the anticipated while overestimated performance standards that others have stimulating fear of scrutiny and contributing to SAD. Differences between these models refer to the attentional focus that is understood as a person's shift to monitoring internal versus external cues. In the first model, treating SAD primarily means to direct the patient's attention toward inward to increase the person's sense of self so that safety behaviors are identified, understood, and finally dropped. In the second model, treatment is aimed at training socially anxious individuals to direct their attention away from the mental representation of the self toward the task at hand and to indicators of nonnegative reactions from others [16].

situations (e.g., oral exams); "humiliation" and "embarrassment" are subsumed under the broader term "negative evaluation," the core fear in SAD; and including patients' sociocultural context allows for the better evaluation of the "excessive or unreasonable" fear described in the former version of the DSM [2, 3]. SAD is associated with considerable psychosocial and occupational handicaps and with an increased risk of comorbid mental impairment and suicidality [4, 5]. Remission rates are low (e.g., 20% in the first 2 years) compared with affective disorders

Cognitive behavioral therapy (CBT) for SAD appears effective in a range of formats demonstrating a general effect size of *d* = 0.70 [7]. Effect sizes however vary considerably. The following parameters have shown substantial influence on CBT's efficacy: *setting*, with larger effect sizes in individual versus group settings; *data collection*, with larger effect sizes in observer ratings (e.g., *d* = 1.93, Liebowitz Social Anxiety Scale (LSAS)) versus self-reports (e.g., *d* = 1.23, LSAS-SR); *number of measures* and *treatment duration*, with larger effect sizes on composite measures in short treatments (e.g., *d* = 2.14 on the Social Phobia Composite, in a 4-month treatment) versus single measures in long treatments (e.g., *d* = 1.23–1.32 on the LSAS-SR, in an 8-month treatment); and *calculation of outcome*, with larger effect sizes calculated by odds ratios of remission and response (e.g., 36–86 and 56–86%, respectively) versus calculation of

On a theoretical and therapeutic level, SAD can be described and treated with a focus on individually impaired internal processes and modes of behavior. This includes the amplitude of emotional life (e.g., unease, nervousness, panic) and somatic experiences (e.g., sweating and hot flashes) in specific social situations. Core cognitive processes refer to dysfunctional beliefs and self-focused attention, limiting the perception of external stimuli. It also includes modes of behavior depending on how strongly the patient avoids the feared situations. On the other hand, SAD can also be described and treated with the focus on the affected social system. This includes problems while interacting with others (e.g., arguing) and one's overall experience within the social system (e.g., belonging, cohesion, flexibility, accord). The convergence of both foci makes SAD an intra- and interpersonal disorder: symptoms of fear arise when the affected person experiences that he or she may attract critical attention from others; these symptoms in turn constrain the person's ability to successfully build and maintain social relationships [14]. **Intrapersonal models.** Cognitive behavioral models on SAD are largely intrapersonal models. There is a common ground between the models of the first generation. *Beck, Emery, and Greenberg* [15] explain SAD by distorted cognitive schemata (e.g., "No matter what I do, I'll make a mistake!") resulting from negative interaction with significant others in early childhood to youth. Once generated, these schemata are activated in stressful and challenging situations in the kind of unconditional negative core beliefs (e.g., "I am inept!") and conditional beliefs (e.g., "If I show myself, I'll behave stupid!"). Successful treatment of SAD should change these problematic negative cognitive schemata. There however still is the question why some schemata do not change though people are exposed to lots of positive situations.

and other anxiety disorders [6]. Thus, effective treatments are in high demand.

**2. Intra- and interpersonal aspects of social anxiety disorders**

pre-post differences [8–13].

50 Cognitive Behavioral Therapy and Clinical Applications

The second generation of cognitive behavioral models of SAD argues that the former approaches are too unspecific considering disorder-specific characteristics and with regard to the importance of the self in understanding SAD. *Hofmann* [17] agrees with the former models in hypothesizing that people with SAD anticipate social standards too high while heavily doubting to achieve them which results in an increased apprehension when entering social situations and heightened self-focused attention. The new component in his model refers to the affected person's strategy to purposefully fail so that others' expectations of them do not increase. People with SAD are described of perceiving their inability to meet expectations in tandem with the deficiency in setting social goals as well as planning and implementing actions for goal attainment. All models so far agree in hypothesizing that socially anxious people have intact social skills, but anxiety, negative cognitions, and avoidance behaviors impede social interactions. Consequently, treating SAD primarily highlights the work with defining and achieving social goals and with improving the patients' perception of their social skills rather than training them in specific skills. *Moscovitch* [18] and Stopa [19] criticize the former models having approached the self too little in understanding SAD. According to Moscovitch [18], they imprecisely concentrated on the negative evaluation as the feared consequence rather than the feared stimulus that occurs in SAD. The feared stimulus refers to the characteristics of the self that the person with SAD perceives as being deficient. It is these selfattributes themselves rather than the social situation, which are the most direct and sensible targets to work with. Self-attributes are understood quite stable compared to the activation of self-schemata at certain times and in certain social situations as proposed by the abovedescribed models. These self-attributes can be divided into four dimensions: (1) perceived deficiency in social skills ("I will make a mistake!"), (2) perceived visibility of anxiety ("I will blush!", "I will sweat!"), (3) perceived deficiency in physical appearance ("I am ugly!"), and (4) perceived personal deficiency ("I am damn stupid!"). Treating SAD thus means the functional analysis of these self-attributes and dimension-specific exposure aiming at the discovery of the person's authentic, non-concealed selves to others in the service of correcting their maladaptive perception of themselves . According to *Stopa* [19], maladaptive self-perception grounds in limited retrieval of multiple self-representations rather than the understanding of the self as a whole and self-attributes to be feared stimuli. The complexity of the self emerges in its conceptualization unfolding three categories: (1) content refers to information about the self (e.g., many negative statements in SAD) as well as the way in which that information is represented (e.g., logical versus figural verbalization) and is addressed by the former cognitive behavioral models when referring to mental representations of the self; (2) process refers to the strategies used to evaluate the self (e.g., higher accessibility to negative information in SAD) and is addressed by the former cognitive behavioral models when speaking of attentional biases; and (3) self-structure refers to the organization of self-knowledge (e.g., priority of negative information in SAD). Consequently, treatments of SAD should create preferential access to more positive and functional self-representations by inhibiting access to negative self-representations.

interacting with others resulting in some sort of self-protective or avoidance behavior. As a consequence, the individual fails to connect with others and to establish healthy and intimate relationships which in turn maintains and even fosters social anxiety. However, the main difference and additional specification, respectively, refer to how agency is attributed to the affected person. Interpersonal models deal with the way people with SAD can elicit negative evaluations to a greater extent compared to the cognitive behavioral models. Russel et al. [33] found that people with SAD displayed increased submissive behavior in feared situations, whereas where they experienced emotional security, they showed complementary affiliative behavior. Such research demonstrates that people with SAD recognize when they can connect

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*Meso-level (friendships and acquaintanceships)*: the intimacy model suggests that reciprocal self-disclosure is crucial for the development of friendships. Meleshko and Alden [34] found socially anxious people less likely to reciprocate the level of intimacy displayed by their interaction partner which resulted in less interest in future contact with them. Vonken et al. [48] found that partners' negative reactions of people with SAD and their perception of dissimilarity together explained substantial variance in the rejection of socially anxious people. It thus can be inferred that it is both the socially anxious person and the interaction partner who participate in the establishment of a negative interpersonal cycle in which both individuals reciprocally attempt to avoid negative emotions while gradually distancing from another, reducing their partner's interest in them and thereby impeding the development of a closer relationship. Similarly to Russel et al. [33], Alden et al. [35] however also found that people with SAD are able to be open with others when they do not anticipate negative reactions.

*Micro-level (intimate relationships)*: as proposed by the above-described interpersonal models, intimate relationships require a complex set of behaviors (e.g., self-disclosure), processes (e.g., complementarity), and cognitions (e.g., felt trust). Research on SAD demonstrated reduction of perceived closeness in socially anxious individuals when confronted with a partner's anticipated negative critique. Contrariwise, the opposite was found for nonsocially anxious individuals [36, 37]. It also appears that people with high SAD symptoms use fewer positive interaction skills (e.g., compliments, empathy, nonverbal behavior) and display more negative communication (e.g., blaming) compared to people with low SAD symptoms. There were no differences in behavior of the partners of socially anxious and nonsocially anxious people [38]. According to the circumplex model described above, individuals with SAD are more likely to choose a partner with a dominant and cold interaction style. However, detailed

**Summary.** The main difference between the intrapersonal (cognitive-behavioral) and interpersonal (social system) models refers to how they define the *central driver of the development and maintenance of SAD*: (1) cognitive behavioral models center cognitive biases and negative core beliefs, whereas social system models emphasize interpersonal functioning; (2) cognitive behavioral models perceive social anxiety characterized by negative self-schemata or fear of personal deficiencies, whereas social system models understand social anxiety as a strategic problem resulting from a variety of reciprocal interactional experience; (3) cognitive behavioral models are engaged with an individual that is highly concerned with failing to live up its

research on partners' characteristics of socially anxious people still is missing.

and that they adjust their behavior depending on the social context.

**Interpersonal models.** Interpersonal models understand social behavior as an interactive process involving at least two social interaction partners who are sensitive to and shaped by the behavior of the other person. The relational literature is extensive, and with the focus on SAD, Alden et al. offer three relational models to illustrate key concepts in adaptive relational functioning. The *circumplex model* [20, 21] allows the description of social interactions on two dimensions, affiliation and dominance, which can be organized to create a circular space. Interactions are perceived more satisfactory when interaction partners display correspondence on affiliation (e.g., friendly actions of one person are faced with friendliness from the interaction partner), and reciprocity on dominance (e.g., dominant behavior meets submissive behavior) [22]. Increasing complementarity has been shown to interact with positive reciprocal social interactions [23–25], while decreasing complementarity is associated with greater interpersonal distress [26]. Kiesler [27] adds the description of an interpersonal transaction cycle which refers to the phenomenon that expectations about the other person influence one's initial behavior and can stimulate a response that in turn confirms the preconceptions in a self-fulfilling prophecy. For example, if a person with SAD expects the other person to negatively evaluate their social interaction, the other person will be more likely to do so. Close relationships, however, need intimacy. In the *intimacy model*, Reis and Shaver [28] understand intimacy as feeling "validated, cared for, and closely connected with another person" (p. 385). It implicates self-disclosure and responsiveness as the two core dimensions which together facilitate rapport in interactions between unacquainted strangers [29] and closeness in partnerships [30]. The *risk regulation model* [31] emphasizes the so-called audacious trust, i.e., the belief that the partner loves one even at times when behavioral cues are less clear, to simulate felt security which in turn is understood as a precondition for commitment in close relationships. Interestingly, and reminiscent of the underpinnings in Stopa's [19] model described above, trust is associated with greater activation of brain structures responsible for regulating social pain accompanied by lower self-report of social pain [32].

Glancing at relational functioning in SAD, interpersonal models strive for the consideration of prosocial concepts (e.g., trust, belonging, security, and responsiveness), extending the well-established research on dysfunctional social interactions. Alden et al. offer a three-level perspective: (a) the macro-level addresses rather loses contacts, (b) the meso-level involves friendships and acquaintanceships, and (c) the micro-level encompasses intimate relationships.

*Macro-level (loose contacts)*: interpersonal models understand SAD to be stimulated by contextualized relational schemata (e.g., "If I show myself in this situation, others will criticize or even reject me!"). Like the cognitive behavioral models, they result from negative interaction with significant others in one's early years. They involve increased negative expectation when interacting with others resulting in some sort of self-protective or avoidance behavior. As a consequence, the individual fails to connect with others and to establish healthy and intimate relationships which in turn maintains and even fosters social anxiety. However, the main difference and additional specification, respectively, refer to how agency is attributed to the affected person. Interpersonal models deal with the way people with SAD can elicit negative evaluations to a greater extent compared to the cognitive behavioral models. Russel et al. [33] found that people with SAD displayed increased submissive behavior in feared situations, whereas where they experienced emotional security, they showed complementary affiliative behavior. Such research demonstrates that people with SAD recognize when they can connect and that they adjust their behavior depending on the social context.

behavioral models when referring to mental representations of the self; (2) process refers to the strategies used to evaluate the self (e.g., higher accessibility to negative information in SAD) and is addressed by the former cognitive behavioral models when speaking of attentional biases; and (3) self-structure refers to the organization of self-knowledge (e.g., priority of negative information in SAD). Consequently, treatments of SAD should create preferential access to more positive and functional self-representations by inhibiting access to negative

**Interpersonal models.** Interpersonal models understand social behavior as an interactive process involving at least two social interaction partners who are sensitive to and shaped by the behavior of the other person. The relational literature is extensive, and with the focus on SAD, Alden et al. offer three relational models to illustrate key concepts in adaptive relational functioning. The *circumplex model* [20, 21] allows the description of social interactions on two dimensions, affiliation and dominance, which can be organized to create a circular space. Interactions are perceived more satisfactory when interaction partners display correspondence on affiliation (e.g., friendly actions of one person are faced with friendliness from the interaction partner), and reciprocity on dominance (e.g., dominant behavior meets submissive behavior) [22]. Increasing complementarity has been shown to interact with positive reciprocal social interactions [23–25], while decreasing complementarity is associated with greater interpersonal distress [26]. Kiesler [27] adds the description of an interpersonal transaction cycle which refers to the phenomenon that expectations about the other person influence one's initial behavior and can stimulate a response that in turn confirms the preconceptions in a self-fulfilling prophecy. For example, if a person with SAD expects the other person to negatively evaluate their social interaction, the other person will be more likely to do so. Close relationships, however, need intimacy. In the *intimacy model*, Reis and Shaver [28] understand intimacy as feeling "validated, cared for, and closely connected with another person" (p. 385). It implicates self-disclosure and responsiveness as the two core dimensions which together facilitate rapport in interactions between unacquainted strangers [29] and closeness in partnerships [30]. The *risk regulation model* [31] emphasizes the so-called audacious trust, i.e., the belief that the partner loves one even at times when behavioral cues are less clear, to simulate felt security which in turn is understood as a precondition for commitment in close relationships. Interestingly, and reminiscent of the underpinnings in Stopa's [19] model described above, trust is associated with greater activation of brain structures responsible for regulating

social pain accompanied by lower self-report of social pain [32].

Glancing at relational functioning in SAD, interpersonal models strive for the consideration of prosocial concepts (e.g., trust, belonging, security, and responsiveness), extending the well-established research on dysfunctional social interactions. Alden et al. offer a three-level perspective: (a) the macro-level addresses rather loses contacts, (b) the meso-level involves friendships and acquaintanceships, and (c) the micro-level encompasses intimate relationships. *Macro-level (loose contacts)*: interpersonal models understand SAD to be stimulated by contextualized relational schemata (e.g., "If I show myself in this situation, others will criticize or even reject me!"). Like the cognitive behavioral models, they result from negative interaction with significant others in one's early years. They involve increased negative expectation when

self-representations.

52 Cognitive Behavioral Therapy and Clinical Applications

*Meso-level (friendships and acquaintanceships)*: the intimacy model suggests that reciprocal self-disclosure is crucial for the development of friendships. Meleshko and Alden [34] found socially anxious people less likely to reciprocate the level of intimacy displayed by their interaction partner which resulted in less interest in future contact with them. Vonken et al. [48] found that partners' negative reactions of people with SAD and their perception of dissimilarity together explained substantial variance in the rejection of socially anxious people. It thus can be inferred that it is both the socially anxious person and the interaction partner who participate in the establishment of a negative interpersonal cycle in which both individuals reciprocally attempt to avoid negative emotions while gradually distancing from another, reducing their partner's interest in them and thereby impeding the development of a closer relationship. Similarly to Russel et al. [33], Alden et al. [35] however also found that people with SAD are able to be open with others when they do not anticipate negative reactions.

*Micro-level (intimate relationships)*: as proposed by the above-described interpersonal models, intimate relationships require a complex set of behaviors (e.g., self-disclosure), processes (e.g., complementarity), and cognitions (e.g., felt trust). Research on SAD demonstrated reduction of perceived closeness in socially anxious individuals when confronted with a partner's anticipated negative critique. Contrariwise, the opposite was found for nonsocially anxious individuals [36, 37]. It also appears that people with high SAD symptoms use fewer positive interaction skills (e.g., compliments, empathy, nonverbal behavior) and display more negative communication (e.g., blaming) compared to people with low SAD symptoms. There were no differences in behavior of the partners of socially anxious and nonsocially anxious people [38]. According to the circumplex model described above, individuals with SAD are more likely to choose a partner with a dominant and cold interaction style. However, detailed research on partners' characteristics of socially anxious people still is missing.

**Summary.** The main difference between the intrapersonal (cognitive-behavioral) and interpersonal (social system) models refers to how they define the *central driver of the development and maintenance of SAD*: (1) cognitive behavioral models center cognitive biases and negative core beliefs, whereas social system models emphasize interpersonal functioning; (2) cognitive behavioral models perceive social anxiety characterized by negative self-schemata or fear of personal deficiencies, whereas social system models understand social anxiety as a strategic problem resulting from a variety of reciprocal interactional experience; (3) cognitive behavioral models are engaged with an individual that is highly concerned with failing to live up its own, whereas social system models deal with an individual that fears to fail up to the expectations of others; and (4) cognitive behavioral models refer to interactions with close persons as well as with complete strangers, whereas social system models have a greater focus on relationships with important others. This becomes obvious when analyzing the understanding of *safety and self-protective behavior*, respectively. Both the cognitive-behavioral and social systems models emphasize these strategies in the light of avoiding scrutiny while exacerbating distorted mental processes in the long term. They however propose different explanations as to why this is the case: most cognitive behavioral models refer to the prevention of habituating to anxiety and correcting their maladaptive perception of how others, even strangers, evaluate them; most social system models refer to the disruption of relationships and the ability to enter meaningful social relationships .

The patient grew up in a highly performance- and achievement-oriented family. He was almost always best at school ("Merit is not my problem!") and developed a couple of good friendship in elementary school and in puberty. In the development of these relationships, time was very important so that the patient got into contact and became intimate with his friends step by step. At all times, he concurrently felt much shyness and great nervousness when being confronted with strangers. He chose the medical studies by his own interest and

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Currently, the patient lived in a shared apartment with fellow students. He did sports, liked

*SCID diagnostics* [39] demonstrated the criteria for SAD and a moderate depressive episode. *Standard diagnostics*: The *Symptom Checklist (SCL-K-9)* [40, 41] showed a superior psychological symptom pressure (T = 72). The *Brief Symptom Checklist (BSI)* [42] showed superior depression (T = 66), social uncertainty (T = 62), and phobic anxiety (T = 64). *Disorderspecific diagnostics*: The *Liebowitz Social Anxiety Scale (LSAS-SR)* [43] total score was at 105 (cutoff, 30), the *Social Interaction Anxiety Scale (SIAS)* at 46 (cutoff, 35), the *Social Phobia Scale (SPS)* at 29 (cutoff, 24) [44, 45], and the *Beck Depression Inventory (BDI)* [46] at 17

**Macroanalysis.** The patient's areas of problem can be interpreted against the context of his life history. A parental home in which the patient felt less secure bonds (e.g., marital quarreling, absence of the father, felt significant age difference between sisters and brothers) but much pressure to perform (e.g., praise for A grades, neglect of B grades, harsh critique for C grades) accounted for strong feelings of humiliation when anticipating failures or negative evaluations. As a consequence, the patient developed dysfunctional core beliefs (e.g., "Excellent performance is essential to be noticed and to survive well in contact with others!") and interpersonal deficits (e.g., lack of perception and inadequate expression of needs; lack of spontaneous contact, communication, and interaction with strangers and authorities). The patient decreasingly experienced positive social contacts and his self-worth strongly reduced. Finally, he limited his social contacts to only those people he had met in childhood and youth and which have grown over years in his hometown. As a consequence, he suffered from depressive decompensation and panic attacks at his uni-

felt much enthusiasm if there were not "these painful heart attacks."

cooking, and spent his weekends with his family and friends at home.

(mild depression).

versity place.

**3.3. Test diagnostics: before therapy started (independent blind diagnostician)**

**3.4. Analysis of behavior and life conditions (macro- and microanalysis)**

**Microanalysis.** The *microanalysis* is displayed in **Table 1**.

The therapy goals and treatment plan are listed in **Table 2**.

**3.5. Therapy goal and treatment plan**
