**1.2. Cognitive behavior therapy: CBT for SAD**

of SAD was 0.8% among Japanese people. This face-to-face household survey involved 1663 adults (overall response rate, 56%) in four communities in Japan, including two cities and two rural population areas. It is also suggested that there is a continuum between social anxieties

Individuals with SAD are often afraid of social situations and social interaction. For example, these situations are public speaking, conversation, telephone, writing, and so on. Individuals, who have excessive fear of public speaking, often avoid this activity because they have various negative cognitive assumptions and images about failure to give an "adequate" performance. Before a speaking session, they feel too much anxiety and perceive physical arousal symptoms. In addition, they think that they will not deliver a good performance and that catastrophic things will happen. When conducting their tasks, they feel that they cannot control outcomes and their performance. They do not look at the faces in their audience and they speak fast. Afterwards they realize that their speech was bad and they will be evaluated as

"negative" or "insignificant" people. Therefore, they usually avoid these situations.

These negative cognition and avoidance behaviors are traditionally summarized in a cognitive model or cognitive behavior model. In this chapter, we report on the previous cognitive behavior therapy (CBT) model of SAD and the technique of CBT for SAD. Additionally, we introduce recent research in mindfulness-based therapy and discuss the future direction of a

Cognitive and cognitive-behavioral models of SAD posit that negative cognition maintains social anxiety symptoms. These models describe the relationships between negative cognition, behavior, and somatic symptoms in SAD. In these models, cognition includes self-focused attention, interpretation, rumination, self-perception, social negative evaluation, and other cognitive values [8, 9]. Clark and Wells [8] suggested that patients with SAD develop a series of negative assumptions and overestimate how negatively other people will evaluate their performance in social situations. In social situations, patients with SAD perceive social danger for themselves. These negative processing biases produce somatic symptoms and behavioral symptoms, which interact to heighten social anxiety symptoms. In their cognitive-behavioral model, Rapee and Heimberg [9] suggested that individuals with SAD and highly socially anxious individuals have a greater expectancy of negative occurrences. Also, they predict a greater cost of these occurrences for themselves than do less anxious individuals in social situations. Additionally, they indicated that these probability and cost estimates are related to state anxiety in social situations.

The estimated social cost of this is a specific expression of dysfunctional beliefs about the potential outcome of a social encounter [10]. The cognitive behavioral model of Hofmann and Otto provided general treatment model of SAD. In the model, maintaining the factors of SAD is discussed and indicates the importance of the overestimation of the negative consequences, the perception of low emotional control, negative self-perceptions, negative rumination, and so on. Symptoms of SAD can be classified into cognitive, behavioral, and physical categories [11]. Cognitive symptoms include negative self-evaluations or catastrophizing what other people think of the individual in social situations. Individuals with SAD may have thoughts such as

or fears and SAD.

116 Anxiety Disorders - From Childhood to Adulthood

psychotherapy that takes SAD into account.

**1.1. The cognitive behavior therapy model**

There are several studies of effective treatment for SAD [13–17]. These treatment programs include psycho-education, exposure, cognitive restructuring, and original interventions. Typical CBT techniques for the treatment of SAD include exposure, applied relaxation, social skills training, and cognitive restructuring [17]. In their meta-analytic review, they reported that the most recommended treatment components of CBT programs are exposure and cognitive restructuring. Clark et al. [18] reported high-effect levels for individual CBT. This program consisted of helping clients to develop a list of personal safety behaviors, conducting self-focused attention experiments where the focus of attention is shifted to social situations, psychoeducation about their model [8], video feedback, behavioral experiments, identification of problematic anticipatory and post-event processing, and modification of assumptions about dysfunction. Depending on the assessment point, uncontrolled effect levels in their study ranged from 2.14 to 2.53.

Rapee et al. [14] examined possible differences between standard cognitive behavioral group therapy (CBGT) and an enhanced CBGT program. Standard CBGT consisted of standard cognitive restructuring plus in vivo exposure. The enhanced CBGT program was augmented with several additional treatment techniques, including performance feedback and attention retraining. These programs were conducted in therapist facilitated groups of approximately six participants. Both types of CBGT package had sufficient improvement on SAD symptoms, with the enhanced treatment showing better effects than standard treatment on the cost of negative evaluation and negative views of one's skills and appearance.

CBT for SAD is classified as both group therapy and individual therapy. Both types of therapies have merits and demerits as discussed in the following section. The merits of group therapy are: (1) presence of others when being exposed in social conditions is useful for increasing the degree of a threat and reality; (2) others' modeling becomes possible in exposure settings; (3) cooperative consciousness among patients toward treatment is developed; and (4) simultaneous intervention for various patients become possible, among others. On the other hand, group therapy has some demerits as follows: (1) presence of others might activate fears of negative evaluation, which might inhibit patients' spontaneous behaviors and speeches; (2) the threat of exposure might increase excessively; (3) the relationships between therapists and patients tend to become weak; and (4) the presence of others might make it difficult for participants to participate in the program, among other problems. The merits of individual therapies are: (1) therapists can easily adapt the program to the cognitive and behavior characteristics of each patient; (2) participation in treatment is easier, compared to group therapy; (3) individual patients' needs and questions are sufficiently dealt with; and (4) participants can freely express their speeches and behaviors without considering others, among other benefits. On the other hand, it is considered difficult to get the merits of group therapy as described earlier through individual therapies, from the perspective of its structure.
