1. Introduction

Social anxiety disorder (SAD), which is the most common type of anxiety disorder, is characterized by fear of negative evaluation by others [1, 2]. SAD impairs social, academic, occupational, and economic functioning of individuals with the disorder [3]. SAD patients and highly socially anxious individuals have many similar psychological and physiological features that only differ in intensity [4, 5]. Moreover, it has been suggested that there are overlaps between shyness, social anxiety, and SAD [6]. Therefore, it is reasonable that SAD symptoms gradually improve the quality of life and functioning in individuals, including those who are socially anxious or who have SAD.

The cognitive and the cognitive behavioral models of SAD suggest that negative cognitions maintain social anxiety symptoms [7, 8]. Clark and Wells [7] indicated that SAD patients develop a series of negative assumptions and overestimate how negatively other people evaluate their performance in one or more social situations. Rapee and Heimberg [8] suggested

© 2018 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

that the distorted self-perception about performance is one type of negative cognition that maintains social anxiety symptoms in SAD patients and socially anxious individuals. Moreover, previous studies have reported that SAD patients and socially anxious individuals show lower self-ratings than other ratings of their performance [9–11].

shown that both individual and group CBT programs are highly effective for treating SAD symptoms [19–25] and have several similarities, in spite of differences in treatment style between them. For example, cognitive restructuring, video feedback, attention training, and exposure

Video Feedback Techniques Used in Social Anxiety Disorders

http://dx.doi.org/10.5772/intechopen.71278

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In recent years, therapeutic intervention programs that include mindfulness have been developed. Mindfulness is defined as "paying attention in a particular way—on purpose, in the present moment and nonjudgmentally" [27]. Research on the applications of mindfulness to SAD is progressing with many studies reporting that mindfulness-based therapy is effective for treating social anxiety symptoms [28]. The improvement of trait mindfulness might affect factors maintaining SAD, such as post-event processing, fear of negative evaluation, avoidance behavior, and self-focused attention [29–32]. Kocovski et al. indicated that trait mindfulness predicts subsequent changes in social anxiety and that social anxiety predicts subsequent change in trait mindfulness [33]. Rasmussen and Pidgeon suggested that higher levels of trait mindfulness predict lower levels of social anxiety symptoms [34]. These approaches have not been used in video feedback research. Perhaps, mindfulness-based psychotherapy combined

Computerized cognitive behavior therapy using the Internet has also been developed internationally. Computerized cognitive behavior therapy (CCBT) programs involve the effective delivery of evidence-based treatments over the Internet, using computers, tablets, and smartphones. CCBT is a self-help treatment. Self-help cognitive behavior therapy (CBT) can provide a useful approach to the treatment of psychological problems. A meta-analysis examined the efficacy of technology-assisted interventions for individuals with SAD [35]. This metaanalysis divided studies into Internet-delivered cognitive behavior therapy (ICBT; 21 trials), virtual reality exposure therapy (VRET; 3 trials), and cognitive bias modification (CBM; 13 trials) and reported that ICBT had a small advantage (g = 0.38) over active control conditions. Moreover, while the efficacy of CBM was limited, substantial evidence regarding ICBT and preliminary evidence for VRET suggest that both could effectively reduce SAD symptoms, which is suggestive of the potential of technology-assisted interventions for SAD. The results showed that ICBT and VRET were effective in reducing SAD symptoms, with VRET having comparable effects and ICBT being more effective than active control groups. The best-known CCBT program for SAD is the SOFIE program, which was developed in 2003 [36] and is the first Internet-based CBT program with demonstrated efficacy. The program consisted of nine modules delivered within 9 weeks, which was subsequently changed to a 15-week version. The components of the SOFIE program were psycho-education, cognitive restructuring, expo-

technique are the main components in both treatment modalities [26].

with video feedback technique could improve treatment efficacy.

sure and attention-shifting exercises, and social skills relapse prevention.

VF, which is based on the cognitive model of SAD [7], involves providing highly socially anxious individuals and people with SAD with video playback of their social performance following the participation in a social task, such as making a public speech or a one-on-one conversation [37]. Participants then watch the situation using the video recording. It is anticipated that the review of the recording would correct their distorted self-evaluations, including

2. Video feedback (VF)

There are two subtypes of SAD, the generalized type and the performance only type [12]. Individuals diagnosed with the generalized type experience excessive fear in almost all social situations, including performance and social interactions. Individuals diagnosed with the performance only type experience excessive fear only in performance situations, such as making a presentation in front of the class, with no major anxiety associated with social interaction per se, such as talking with friends or strangers. Furmark et al. reported that individuals with the generalized type exhibit more social distress and impairment [13]. These impairments might include holding a cup firmly, avoiding eye contact, or speaking softly. People with SAD use such safety behaviors to reduce their anxiety, but these behaviors can exclude opportunities to learn what happens in social situations and might cause further anxiety due to decreased coping efficacy. Their physical symptoms might involve displays of physiological arousal in social situations that include shaking, sweating, heart throbbing, and other manifestations of anxious arousal. People with SAD also tend to exaggerate the extent to which these symptoms are visible to others, which leads to more concerns about negative evaluation from others.

Many previous studies have indicated that cognitive-behavioral therapy (CBT) techniques are effective in the psychological treatment of SAD [14–16]. According to Rodebaugh et al. [16], typical CBT techniques for the treatment of SAD include exposure, applied relaxation, social skills training, and cognitive restructuring. In a meta-analytic review, they reported that the most recommended treatment component of CBT programs is exposure and cognitive restructuring [16].

Video feedback is also included in most CBT treatment programs. After exposure and cognitive restructuring sessions, individuals with SAD try to watch videos of themselves, before receiving cognitive preparation. Clark et al. reported the high efficacy of individual CBT [17]. Their program consisted of developing personal safety behaviors and self-focused attention with patients by shifting the focus of attention to social situations. Based on Clark and Wells' model, patients try to identify the relationship between their own cognition and SAD symptoms on psycho-education sessions. Additionally, video feedback was used to modify distorted self-imagery. Participants try to improve the discrepancy between their negative, distorted self-images and their objective social performance.

In video feedback sessions, individuals with SAD watch themselves doing actual social tasks, such as public speaking and conversation tasks. They often recognize their performance to be worse than their actual performance. Then, therapists try to improve the discrepancy between subjective and objective perceptions of social performance. For example, Shirotsuki et al. attempted to examine the effects of an individual CBT program that included exposure, cognitive restructuring, and video feedback techniques [18] using video feedback of speech tasks. The results indicated that the program was effective for improving social anxiety symptoms and selfperception during speech tasks, suggesting that individuals with SAD can improve their negative self-perceptions and negative estimations before a speech task. Previous research has also shown that both individual and group CBT programs are highly effective for treating SAD symptoms [19–25] and have several similarities, in spite of differences in treatment style between them. For example, cognitive restructuring, video feedback, attention training, and exposure technique are the main components in both treatment modalities [26].

In recent years, therapeutic intervention programs that include mindfulness have been developed. Mindfulness is defined as "paying attention in a particular way—on purpose, in the present moment and nonjudgmentally" [27]. Research on the applications of mindfulness to SAD is progressing with many studies reporting that mindfulness-based therapy is effective for treating social anxiety symptoms [28]. The improvement of trait mindfulness might affect factors maintaining SAD, such as post-event processing, fear of negative evaluation, avoidance behavior, and self-focused attention [29–32]. Kocovski et al. indicated that trait mindfulness predicts subsequent changes in social anxiety and that social anxiety predicts subsequent change in trait mindfulness [33]. Rasmussen and Pidgeon suggested that higher levels of trait mindfulness predict lower levels of social anxiety symptoms [34]. These approaches have not been used in video feedback research. Perhaps, mindfulness-based psychotherapy combined with video feedback technique could improve treatment efficacy.

Computerized cognitive behavior therapy using the Internet has also been developed internationally. Computerized cognitive behavior therapy (CCBT) programs involve the effective delivery of evidence-based treatments over the Internet, using computers, tablets, and smartphones. CCBT is a self-help treatment. Self-help cognitive behavior therapy (CBT) can provide a useful approach to the treatment of psychological problems. A meta-analysis examined the efficacy of technology-assisted interventions for individuals with SAD [35]. This metaanalysis divided studies into Internet-delivered cognitive behavior therapy (ICBT; 21 trials), virtual reality exposure therapy (VRET; 3 trials), and cognitive bias modification (CBM; 13 trials) and reported that ICBT had a small advantage (g = 0.38) over active control conditions. Moreover, while the efficacy of CBM was limited, substantial evidence regarding ICBT and preliminary evidence for VRET suggest that both could effectively reduce SAD symptoms, which is suggestive of the potential of technology-assisted interventions for SAD. The results showed that ICBT and VRET were effective in reducing SAD symptoms, with VRET having comparable effects and ICBT being more effective than active control groups. The best-known CCBT program for SAD is the SOFIE program, which was developed in 2003 [36] and is the first Internet-based CBT program with demonstrated efficacy. The program consisted of nine modules delivered within 9 weeks, which was subsequently changed to a 15-week version. The components of the SOFIE program were psycho-education, cognitive restructuring, exposure and attention-shifting exercises, and social skills relapse prevention.
