**1.1. Social anxiety disorders**

SAD is among the most prevalent mental disorders (lifetime prevalence, 7–16%) [1]. It is characterized by fear of negative evaluation (e.g. rejection, humilation, embarrassment) or offending others lasting six or more months, accompanied by actively avoiding social situations, or staying with them with intense fear or anxiety. The fear is out of proportion to the actual threat posed by the social situation, depending on the sociocultural context. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) updated SAD criteria with a special focus on separating social interactions (e.g., conversations), felt observation (e.g., dinner), and performance

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

*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

Cognitive Behavioral Therapy for Social Anxiety Disorder: Intrapersonal and Interpersonal…

http://dx.doi.org/10.5772/intechopen.74302

51

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

task at hand and to indicators of nonnegative reactions from others [16].

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 pre-post differences [8–13].
