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Approach and avoidance motivational changes over the course of Emotion Regulation Therapy (ERT) were assessed at pre-, mid-, and post-treatment using an Approach-Avoidance variant of the Implicit Association Test (AAIAT) that specifically targeted implicitly-held action tendencies about approach/avoidance in the context of positively and negatively valenced word stimuli. We expected implicit associations would be demonstrated by reduced AAIAT Total scores from mid- to post-treatment potentially reflecting increased approaching of contexts regardless of valence. We hypothesized that: (1) AAIAT performance would be responsive to ERT during the second half of treatment when the intervention is specifically focused on exposure to approach-avoidance conflict; (2) changes in AAIAT performance during this period would be associated with changes in clinical outcomes; (3) changes in clinical outcomes during the first half of treatment would not be associated with changes in AAIAT performance occurring in the second half. As expected, AAIAT performance significantly changed from mid- to post-treatment, reflecting an increased likelihood of approaching contexts regardless of valence. These changes were related to improvements in quality of life, functional impairment, and negative emotional intensity. ERT shows promise in changing maladaptive approach/avoidance motivational tendencies for individuals with distress disorders, particularly during the second half, when treatment is focused on approach-avoidance content. This study underscores the value of implementing behavioral tasks as complementary tools to self-report measures in furthering our understanding of core mechanisms (e.g., motivation) implicated in the psychopathology and treatment of distress disorders.

Exposure therapy has been investigated as a treatment for eating disorders, but prior research has largely neglected core fears underlying the disorder such as rejection, abandonment, disgust, and loss of control. We tested the feasibility and acceptability of using imaginal exposure to target disordered eating related fears by randomizing participants ( N = 47) with disordered eating to: imaginal exposure (IE), imaginal exposure preceded by a brief food exposure (IE + Food), or an assessment control. Participants attended two in-person visits and completed pretreatment, posttreatment, and one-month follow-up questionnaires. IE was rated more acceptable than IE + Food. Retention was high across conditions. Habituation occurred for subjective distress and believability of feared outcomes, suggesting that imaginal exposure effectively activates core fears. Distress tolerance and confidence in ability to change improved. Disordered eating symptoms, fears, preoccupations, and rituals decreased in all conditions, indicating that IE was not specifically responsible for improvement.

Social anxiety disorder (SAD) is characterized by negative self-referential processing, which triggers excessive emotional reactivity. In healthy individuals, positive self-views typically predominate and are supported by regions of the default mode network (DMN) that represent self-related information and regions of the frontoparietal control network (FPCN) that contribute to metacognitive awareness and emotion regulation. The current study used functional magnetic resonance imaging (fMRI) to examine patterns of DMN and FPCN activation during positive and negative self-referential judgments in SAD patients (N = 97) and controls (N = 34). As expected, SAD patients demonstrated a striking difference in self-beliefs compared with non-anxious healthy controls, endorsing fewer positive traits and more negative traits. However, SAD patients and controls demonstrated largely similar patterns of DMN and FPCN recruitment during self-referential judgements. No significant group differences were observed. However, equivalence testing identified numerous regions demonstrating effect sizes that were not small enough to conclude that they were practically equivalent to zero, despite the nonsignificant null hypothesis test. These regions may be key targets to investigate in future studies using larger samples.

Postevent processing (PEP), the engagement in detailed and repetitive self-focused review of one’s performance in social situations, is theorized to maintain pathological social anxiety. However, little is known about interventions that may impact this maintenance factor. The current study examined the impact of brief mindfulness training (BMT) on PEP among socially anxious individuals. There were 77 participants (75.32% female, 63.64% non-Hispanic/Latinx White) with clinically elevated social anxiety who attended one appointment in the laboratory during which they were randomized to receive a brief mindfulness-based training (n = 37) or no training (i.e., thinking as usual control group; n = 40). After the training period, participants underwent a 3-minute social anxiety induction task, after which they were instructed to apply their thinking strategy. Participants were then asked to complete 2 weeks of daily online surveys that included a PEP induction task, instructions to use their thinking strategy following PEP induction, and a measure of state PEP. Individuals in the BMT condition reported a significant reduction in state anxiety posttraining compared to individuals in the control condition. Conditions did not differ on state PEP after the social anxiety induction task. However, compared to those in the control condition, participants in the BMT condition reported significantly greater decreases in state PEP over the 14-day follow-up period. Thus, this brief mindfulness-based strategy may be useful for individuals with clinically elevated social anxiety who engage in PEP, a cognitive vulnerability factor implicated in the maintenance of social anxiety.

Background . Cognitive-behavioral therapy and mindfulness-based stress reduction (MBSR) are two prominent evidence-based treatments for social anxiety disorder (SAD). It is not clear, however, whether outcomes of these two treatments are moderated by similar factors. For example, whereas anger suppression and anger expression each predict outcomes in cognitive- behavioral group therapy (CBGT), it is unknown whether they differentially influence outcomes in CBGT versus MBSR. Methods . One hundred eight participants with SAD were randomized to CBGT, MBSR or Waitlist (WL). WL participants were later randomized to CBGT or MBSR, and their data were combined with data from those originally randomized to CBGT or MBSR. Anger suppression and anger expression were assessed at pre-treatment, and social anxiety was assessed at pre-treatment, post-treatment, and every 3 months throughout a 12-month follow-up period. Results . From pre- to post-treatment, higher anger suppression was associated with significantly greater reduction in social anxiety in CBGT compared with MBSR. From post-treatment through follow-up, higher anger expression was associated lesser reduction in social anxiety in MBSR but not in CBGT. Limitations . Data are limited by sole reliance on self-report and it is unclear whether these findings generalize beyond group-based interventions. Conclusions . Individuals with SAD who are higher in anger suppression and/or expression might be better suited to CBGT than MBSR.

We examined the outcomes of individual cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) in a sample of 93 adults seeking treatment in a university outpatient clinic specializing in CBT for SAD. Treatment followed the structure of a manual, but number of sessions varied according to client needs. After approximately 20 weeks of therapy, patients' social anxiety had decreased and their quality of life had increased. Patients with more severe SAD or comorbid major depressive disorder (MDD) at pretreatment demonstrated higher levels of social anxiety averaged across pre- and posttreatment. However, clinician-rated severity of SAD, comorbid MDD, or comorbid generalized anxiety disorder did not predict treatment outcome. Higher pretreatment scores on measures of safety behaviors and cognitive distortions were associated with higher social anxiety averaged across pre- and posttreatment and predicted greater decreases from pre- to posttreatment on multiple social anxiety outcome measures. We found no predictors of change in quality of life. Those with high levels of safety behaviors and distorted cognitions may benefit more from CBT, perhaps due to its emphasis on targeting avoidance through exposure and changing distorted thinking patterns through cognitive restructuring methods. Our study lends support to the body of research suggesting that manualized CBT interventions can be applied flexibly in clinical settings with promising outcomes for patients over a relatively short course of therapy.

Given the strong associations of social anxiety disorder (SAD) with interpersonal problems and insecure attachment, this study sought to examine specific interpersonal problem domains in relation to the outcome of cognitive-behavioral therapy (CBT) for SAD. Ninety-five adults with SAD received individual CBT and completed a measure of attachment style at pretreatment, as well as measures of interpersonal problems and social anxiety at pre- and posttreatment. At baseline, social anxiety was significantly associated with overall interpersonal problems, multiple specific interpersonal problems, as well as insecure attachment. Interpersonal problems decreased significantly over the course of treatment but did not predict a reduction in social anxiety. No specific interpersonal problem predicted changes in social anxiety. The greatest changes from pre- to posttreatment were observed across avoidance-related interpersonal problems. Higher levels of secure attachment predicted lower social anxiety, but individuals with less secure attachment experienced a greater reduction in social anxiety from pre- to posttreatment. However, this interaction was significant for only one of three measures of social anxiety. Our findings suggest that although higher levels of interpersonal problems and lower levels of secure attachment predict greater social anxiety, interpersonal problems and insecure attachment do not predict poorer treatment outcome.

Introduction: The Cognitive Distortions Questionnaire (CD-Quest) is a self-report questionnaire that assesses common cognitive distortions. Although the CD-Quest has excellent psychometric properties, its length may limit its use. Methods: We attempted to develop short-forms of the CD-Quest using RiskSLIM - a machine learning method to build short-form scales that can be scored by hand. Each short-form was fit to maximize concordance with the total CD-Quest score for a specified number of items based on an objective function, in this case R2, by selecting an optimal subset of items and an optimal set of small integer weights. The models were trained in a sample of US undergraduate students (N = 906). We then validated each short-form on five independent samples: two samples of undergraduate students in Brazil (Ns = 182, 183); patients with depression in Brazil (N = 62); patients with social anxiety disorder in the US (N = 198); and psychiatric outpatients in Turkey (N = 269). Results: A 9-item short-form with integer scoring was created that reproduced the total 15-item CD-Quest score in all validation samples with excellent accuracy (R2 = 90.4-93.6%). A 5-item ultra-short-form had good accuracy (R2 = 78.2-85.5%). Discussion: A 9-item short-form and a 5-item ultra-short-form of the CD-Quest both reproduced full CD-Quest scores with excellent to good accuracy. These shorter versions of the full CD-Quest could facilitate measure-ment of cognitive distortions for users with limited time and resources.

Background: Loneliness is a universal experience that is particularly relevant to social anxiety. However, research has not examined loneliness among treatment-seeking individuals with social anxiety disorder (SAD) or assessed whether mal-adaptive or adaptive emotion regulation strategies moderate the relationship between social anxiety and loneliness. Methods: We examined the baseline scores of individuals with SAD (n = 121) who sought treatment as part of a waitlist-controlled trial of cognitive behavioral group therapy versus mindfulness-based stress reduction. Healthy controls (n = 38) were also examined. Results: Individuals with SAD exhibited greater social anxiety (SA), greater loneliness, more frequent expressive suppression (ES), and less frequent cognitive reappraisal (CR) than controls. Hierarchical multiple regressions indicated that emotion regulation variables moderated the relationship between social anxiety and loneliness. At lower CR and higher ES, there was a positive relationship between social anxiety and loneliness. At higher CR and lower ES, there was unexpectedly a stronger positive relationship between social anxiety and loneliness. Higher SA was associated with higher loneliness regardless of emotion regulation strategy, whereas lower SA was associated with more moderate and lower levels of loneliness dependent on level of ER strategy. Discussion: Implications for understanding the prevalence and burden of loneliness among individuals with SAD, the role of emotion regulation in the relationship between social anxiety and loneliness, and directions for future research are discussed.

Social anxiety disorder (SAD) has been shown to be associated with difficulty in the ability to vicariously share others' positive emotions (positive affective empathy). Mixed evidence also suggests potentially impaired recognition of the positive and negative emotions of others (cognitive empathy) and impaired or enhanced sharing of the negative emotions of others (negative affective empathy). Therefore, we examined whether two efficacious treatments for SAD, cognitive-behavioral group therapy (CBGT) and mindfulness-based stress reduction (MBSR), improve empathy in SAD relative to a wait-list condition and whether improvements in empathy mediate improvements in social anxiety. In the context of a randomized controlled trial, participants with SAD completed an empathy task at baseline, posttreatment/wait-list (N = 81), and 1-year follow-up (N = 37). Relative to both MBSR and wait-list, CBGT resulted in significant improvements in positive affective empathy. CBGT-related changes in positive affective empathy also mediated improvements in social anxiety at both posttreatment/wait-list and at 1-year follow-up. Other indices of empathy did not change differentially across the three conditions. Therefore, one way in which CBGT may specifically confer benefits to individuals with SAD is through increasing their ability or willingness to share in the positive emotions of others.

This chapter discusses the efficacy of cognitive behavioral therapy (CBT) for the treatment of social anxiety disorder (SAD). SAD is a mental health condition marked by impairment and distress across a number of social situations. Manual-based, workbook-driven protocols for CBT for SAD hold promise for promoting evidence-based practice across clinical settings. Not only does the protocol offer a structured framework to guide therapists through therapy sessions, but it also provides clients with their own set of resources to bolster what is learned in the therapy room and bring it into their daily lives. These materials emphasize the importance of a person-centered approach to treatment that can be applied flexibly and adapted to the needs of the individual client. Although key components of the treatment are required for fidelity, there is substantial flexibility built into the structure of the protocol and each component, including the number of treatment sessions, the approach to cognitive restructuring, the content of the fear and avoidance hierarchy, the focus of exposure exercises conducted in session and as homework assignments, as well as how comorbid psychological disorders are addressed.

Transgender and gender nonconforming (TGNC) individuals are at heightened risk for psychological distress, including social anxiety (SA). The current study aimed to examine whether gender-affirming medical interventions (GAMIs) are associated with lower SA among TGNC individuals. Two hundred ninety-one transfeminine and 424 transmasculine participants completed the Trans Health Survey, which assessed SA and interest in or utilization of GAMIs (genital surgery, chest surgery, hormone use, speech therapy, tracheal shave or Adam's apple removal, hair removal). Transfeminine individuals who had completed genital surgery, chest surgery, tracheal shave or Adam's apple removal, hair removal, hormone treatment, or speech therapy reported lower SA than those planning to undergo the intervention, and those who had completed genital or chest surgery reported lower SA than those considering it. Transmasculine individuals who had completed chest surgery, a hysterectomy, or used hormones reported lower SA than those who were planning to do so, and those who had completed genital surgery had lower SA than those considering it. Among those expressing interest, utilization of GAMIs is associated with less SA. GAMIs may result in greater conformity to societal expectations regarding binary gender norms, thus decreasing discrimination, rejection, victimization, and nonaffirmation. Increased alignment of physical characteristics and gender identity may increase self-esteem. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Health anxiety is associated with reassurance-seeking behaviors, including persistent medical care utilization. The current study sought to identify targetable and underlying (transdiagnostic) factors that may influence the relationship between health anxiety and medical care utilization. We examined the role of both anxiety sensitivity (AS; fear of arousal-related sensations) and intolerance of uncertainty (IU; fear of the unknown) in the relationship between health anxiety and likelihood of utilization of general, specialist, and emergency care among 566 adults (Mage = 20.47, SD = 3.54, 79.9% female). A three-way interaction revealed that AS strengthened the association between health anxiety and likelihood of general medical care utilization within the context of higher, but not lower, levels of IU. Only the main effects of AS and IU were significantly associated with odds of emergency care utilization, and there were no significant predictors of odds of specialist care utilization. Future directions and clinical implications are discussed.

Social anxiety disorder (SAD) and major depressive disorder (MDD) are highly comorbid, and together they result in greater functional impairment and a poorer prognosis than either condition alone. Theoretical models implicate impairments in emotion regulation in the development and maintenance of internalizing disorders, yet there has been no systematic comparison of emotion regulation in social anxiety and depression. The current review presents an in-depth examination of the literature on two widely-studied emotion regulation strategies, expressive suppression (ES) and cognitive reappraisal (CR), in SAD and MDD. Our review indicated that SAD is broadly characterized by an overreliance on ES, which is associated with negative social and emotional consequences. SAD is also characterized by ineffective utilization of CR, which inhibits the potential positive emotional benefits of this adaptive emotion regulation strategy. In contrast, MDD is broadly characterized by an underutilization of CR, which may be particularly detrimental in stressful or uncontrollable situations. For both SAD and MDD, treatment intervention appears to address deficits in CR but not ES. After reviewing the literature, we propose multiple pathways by which impairments in ES and CR may increase risk for the co-occurrence of SAD and MDD. Clinical implications and future research directions are also discussed.

Objective Despite the high prevalence of nonsuicidal self-injury (NSSI), no research has systematically studied the occurrence and effects of stigmatization by others towards NSSI scarring. Methods The current study measured implicit and explicit attitudes among undergraduates towards NSSI scarring using the implicit association test and questionnaires to compare implicit and explicit biases towards NSSI with biases towards tattoos, a culturally sanctioned form of self-determined marking, as well as nonintentional disfigurement. Results Our study demonstrated strong negative implicit and explicit biases towards NSSI when comparing NSSI to tattoos and nonintentional disfigurement. Conclusions Results extend previous research describing stigma towards mental illness and suggest a large negative bias towards NSSI. The importance of studying how stigma affects those who bear scarring from NSSI is discussed.

The evidence supporting the relationship between intolerance of uncertainty (IU), a cognitive construct well established in the anxiety literature, and depression is mixed. Some research has demonstrated a direct association between IU and depression, whereas other studies suggest that IU is either unrelated or indirectly related to depression through other pathways, including anxiety. The present study aimed to further elucidate the relationship between IU and depression in an undergraduate sample (N = 221). We posited a model in which worry and anxiety account for unique variance in the association between IU and depression. Results supported this hypothesis. Worry and trait anxiety significantly accounted for unique variance in the relationship between IU and depression. Furthermore, the model that best fit the data included two additional direct paths, from IU to anxiety and from worry to depression, and excluded the direct path from IU to depression. Our findings support the notion that IU and depression are indirectly related through worry and anxiety. Limitations and future directions are discussed.

Introduction Individuals with social anxiety disorder (SAD) are at elevated risk of loneliness, yet little research has examined loneliness in this population. Cognitive-behavioral group therapy (CBGT) and mindfulness-based stress reduction (MBSR) have demonstrated efficacy in treating SAD, yet research has not examined whether they lead to reductions in loneliness. Methods This sample comprised 108 individuals with SAD who were randomized to CBGT, MBSR, or a waitlist control (WL); WL participants were re-randomized to CBGT or MBSR following WL. Assessments were completed pre- and post-treatment, and 3-, 6-, 9-, and 12-month follow-up assessments. Results Compared to WL, individuals in CBGT and MBSR were less lonely at post-treatment; there was no difference between treatments after treatment or during follow-up. Greater reductions in social anxiety from pre- to post-treatment predicted lower levels of loneliness during follow-up. Greater reductions in loneliness from pre- to post-treatment also predicted lower levels of social anxiety during follow-up. Discussion Individuals who experience reductions in their social anxiety during treatment may also feel less lonely following treatment. Reductions in loneliness also lead to improvements in social anxiety. Future research should continue to examine the relationship between social anxiety and loneliness and how interventions for SAD may help reduce loneliness.

Historically, cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) has been evaluated in randomized-controlled trials as a 12-16 session treatment and has demonstrated response rates ranging from 58% to 75%. Despite these promising results, some patients do not improve substantially after this short course of CBT. It is unclear whether non-responding patients would make substantial improvements in social anxiety with further treatment. In a university outpatient clinic specializing in CBT for SAD, we compared outcomes for patients who ended treatment after approximately 20 sessions of CBT (

Social anxiety disorder (SAD) is characterized by negative self-beliefs and altered brain activation in the default-mode network (DMN). However, the extent to which there is neurocognitive heterogeneity in SAD remains unclear. We had two independent samples of patients perform a self-referential encoding task and complete self-reports of childhood maltreatment, subjective well-being, and emotion regulation. In the replication sample, we also measured DMN activation using functional MRI. We used k-means clustering, which revealed two distinct subgroups of patients with SAD in the discovery sample. Cluster 1 demonstrated higher levels of negative self-referential trait endorsement, lower levels of positive self-referential trait endorsement, and significantly higher levels of childhood emotional maltreatment, lower subjective well-being, and altered emotion-regulation-strategy use. A similar pattern was observed in the replication sample, which further demonstrated higher DMN activation during negative trait judgments in Cluster 1. Participants in the SAD clusters, from both the discovery and replication samples, were significantly distinct from samples of control participants. These findings reveal neurocognitive heterogeneity in SAD and its relationship to emotional maltreatment.

Higher weight individuals experience frequent weight-related discrimination, which is associated with exercise avoidance. Exercise is a health behavior with multiple physical and mental health benefits and should be accessible to all. The current study examined another factor that might influence exercise in addition to weight stigma: social anxiety (SA). Given the often public nature of exercise, individuals with SA may feel scrutinized when exercising, which may lead to avoidance. This study examined whether SA moderates the relationship between body mass index (BMI) and exercise and whether SA and its interaction with BMI predict exercise behavior after accounting for weight stigma. We administered an online survey to 603 undergraduates (72 % female, 60 % White). SA was not significantly associated with BMI, but it was positively associated with weight stigma and exercise-avoidance motivation and negatively associated with self-reported exercise. SA moderated the relationship between BMI and exercise-avoidance motivation; individuals with higher BMIs were motivated to avoid exercise, but only if they reported higher SA. This interaction predicted exercise-avoidance motivation after accounting for weight stigma and its interaction with BMI. However, SA did not moderate the relationship between BMI and self-reported exercise. SA may be associated with exercise avoidance among higher weight individuals.

The Five Facet Mindfulness Questionnaire is a widely used measure assessing 5 aspects of mindfulness. The

We examined the lifetime prevalence of anxiety disorders (ADs) among adolescents with lifetime intermittent explosive disorder (IED), as well as the impact of co-occurring ADs on anger attack frequency and persistence, additional comorbidity, impairment, and treatment utilization among adolescents with IED. IED was defined by the occurrence of at least three anger attacks that were disproportionate to the provocation within a single year. Data were drawn from the National Comorbidity Survey-Adolescent Supplement (N = 6,140), and diagnoses were based on structured lay-administered interviews. Over half (51.89%) of adolescents with IED had an AD, compared to only 22.88% of adolescents without IED. Compared to adolescents with IED alone, adolescents with IED and comorbid ADs: (a) were more likely to be female; (b) reported greater impairment in work/school, social, and overall functioning; (c) were more likely to receive an additional psychiatric diagnosis, a depressive or drug abuse diagnosis, or diagnoses of three or more additional disorders; and (d) had higher odds of receiving any mental/behavioral health treatment as well as treatment specifically focused on aggression. Adolescents with IED alone and those with comorbid ADs did not differ in the number of years experiencing anger attacks or the highest number of anger attacks in a given year. ADs frequently co-occur with IED and are associated with elevated comorbidity and greater impairment compared to IED alone. Gaining a better understanding of this comorbidity is essential for developing specialized and effective methods to screen and treat comorbid anxiety in adolescents with aggressive behavior problems.

Objective Evidence suggests that individuals without a history of nonsuicidal self-injury (NSSI) are likely to view NSSI as a stigmatized behavior. However, there is limited evidence evaluating the presence of self-stigma among individuals who have engaged in NSSI. Methods We recruited a university sample (n = 351) and employed implicit and explicit measures to examine the degree of stigmatization toward those with NSSI scarring, as compared to nonintentional disfigurement (i.e., accidental scarring) and to tattoos (i.e., a culturally sanctioned form of intentional tissue alteration). We examined the extent to which bias is related to indicators of NSSI severity among those with a history of NSSI. Results We provide evidence that negative biases toward NSSI may represent the effects of self-stigma. However, findings suggest that biases were generally attenuated among participants with a history of NSSI as compared to those without. Participants who had lower levels of NSSI explicit bias were more likely to have a history of more severe engagement in NSSI; however, no significant relationships were found between implicit bias and NSSI severity indicators. Conclusions We present a theoretical rationale for attenuated biases among individuals with a history of NSSI and discuss implications of this research for NSSI recovery.

This final chapter focuses on assessment of progress, relapse prevention, and termination. After approximately 15 sessions of treatment for the typical client with moderately severe symptoms, it is time to stop and assess progress. Treatment for social anxiety may continue with the same interventions, additional interventions may be added, all treatment may end, or treatment may shift to focus on other issues. Assessment of progress involves reviewing the progress checklist shown at the beginning of chapter 13 in the Client Workbook and re-rating the Fear and Avoidance Hierarchy. It is normal for some social anxiety to remain, but the avoidance ratings should be dramatically reduced.

This chapter builds on the first two steps of cognitive restructuring that were developed in chapter 5: (a) the identification of automatic thoughts (ATs) and the emotions they cause and (b) the identification of thinking errors. This chapter presents the remaining steps in cognitive restructuring: (c) challenging ATs by using disputing questions and (d) generating rational responses. The session opens with a review of the Social Anxiety Session Change Index and homework, and then each concept is covered. There is also a brief discussion in anticipation of the first exposure in the next session. The first in-session exposure is a key moment in treatment.

Additional techniques to challenge automatic thoughts are presented in this chapter. These techniques include the pie chart technique, in which a pie chart can help clients examine catastrophic fears. The continuum technique can be used to help clients put possible negative outcomes in the proper perspective. The me–not me technique is intended to help therapists and clients maintain an awareness that anxiety in certain social situations is expected and even appropriate. The technique of intentional physiological arousal induction involves having the client engage in an activity like jogging in place or walking quickly up and down flights of stairs prior to engaging in an exposure. Video feedback is another potentially powerful intervention.

Many individuals in treatment for social anxiety have some difficulty with casual conversations, even if it is not the primary focus of treatment. The chapter explores why it is important to be able to make casual conversation and then examines some of the automatic thoughts that socially anxious individuals often have in casual conversation and how to challenge those automatic thoughts. This chapter presents psychoeducational material about the importance of small talk in everyday life. Two primary messages from this material are (a) casual conversations are the gateways to more significant relationships and (b) such conversations are, by definition, about inconsequential topics. The chapter talks about two key types of situations in which many people experience social anxiety—conversations and public speaking.

This chapter introduces the idea of information-processing biases using the “amber-colored glasses” metaphor. Although information-processing biases are well established in the research literature, this is a difficult concept to communicate to socially anxious individuals. By describing the amber-colored glasses as a natural outcome of a particular combination of genetics, family environment, and important experiences, the therapist can indicate that the way in which the client processes information makes sense; it just may not be functional. The chapter also covers identification of automatic thoughts (ATs) and finding logical errors (the identification of thinking errors) in ATs. The notion of ATs is used extensively throughout treatment.

This final chapter focuses on assessment of progress, relapse prevention, and termination. After approximately 15 sessions of treatment for the typical client with moderately severe symptoms, it is time to stop and assess progress. Regardless of how much progress an individual has made in overcoming social anxiety, there are important habits to develop to continue making progress. If treatment ends at this time, this chapter discusses when it might be necessary to call the therapist for a booster session. If it is the end of treatment, this is the beginning of the client’s personal journey equipped with a toolbox full of skills and increased confidence to continue to take life in a new direction.

Additional techniques to challenge automatic thoughts are presented in this chapter. These techniques include the “pie chart technique,” in which a pie chart can help clients examine catastrophic fears. The “continuum technique” can be used to help clients put possible negative outcomes in the proper perspective. The “me–not me” technique is intended to help therapists and clients maintain an awareness that anxiety in certain social situations is expected and even appropriate. The technique of “intentional physiological arousal induction” involves having the client engage in an activity like jogging in place or walking quickly up and down flights of stairs prior to engaging in an exposure. “Video feedback” is another potentially powerful intervention.

This chapter helps clients understand more about their own anxiety in the context of the cognitive–behavioral model. The three components of anxiety (physiological, cognitive, and behavioral) are presented, as well as a thorough discussion of avoidance. Avoidance is often a big problem for people with social anxiety because avoiding a few situations that make a person anxious can quickly snowball into a general pattern of avoiding many situations. When people become anxious, they rarely experience just one of the components of anxiety. The cognitive, physiological, and behavioral components interact with each other, and an increase or decrease in one may cause increases or decreases in the other two. The three components of treatment are also discussed. These are systematic graduated exposure, cognitive restructuring, and homework assignments.

After the first in-session exposure, treatment enters a middle phase in which sessions (typically five to six in the recommended 16-session treatment program) revolve around the routine of in-session exposures and review and assignment of in vivo exposures for homework. Exposures are guided by the client’s Fear and Avoidance Hierarchy. For clients to benefit from this treatment, they must begin to engage in anxiety-provoking activities in their daily lives. It is essential that the therapist encourage this by carefully assigning and reviewing homework for in vivo exposure. At the beginning of each session, the therapist reviews the client’s completed Be Your Own Cognitive Therapist Worksheet and comments on aspects that show progress or use of cognitive restructuring skills. At a minimum, clients should engage in at least one in vivo exposure every week. As treatment progresses, this rate should increase if possible.

After the first in-session exposure, treatment enters a middle phase in which sessions revolve around the routine of in-session exposures and review and completion of in vivo (real-life) exposures for homework. Exposures are guided by the client’s Fear and Avoidance Hierarchy. For clients to benefit from this treatment, the emphasis for clients will shift from exposures done in session (with the therapist) to tackling real-life situations on their own. Guidelines for picking exposure situations are provided, and the relationship among exposures, cognitive restructuring, and homework is presented. Homework for the rest of the program is discussed, and learning to overcome social anxiety is introduced as a habit.

The primary purpose this chapter is to finish presentation to the client of the cognitive–behavioral therapy (CBT) model, with a discussion of the etiology and maintenance of social anxiety. Clients vary on how much they want to know about some of the details; however, nearly everyone asks about etiology at some point in treatment. This chapter includes the beginning of monitoring progress using the Social Anxiety Session Change Index (SASCI). From this point in therapy forward, at the beginning of each session, clients complete the SASCI. The chapter is an opportunity to reinforce the basics of the CBT model.

The primary purpose of this chapter is to finish presentation of the cognitive–behavioral therapy (CBT) model with a discussion of the etiology and maintenance of social anxiety. Clients vary on how much they want to know about some of the details. However, nearly everyone asks about etiology at some point in treatment. Possible causes of social anxiety include a genetic component, family environment, and important experiences. However, most psychologists agree that social anxiety disorder, like most other psychological disorders, is not caused by just one thing and results from a combination of factors. This chapter includes the beginning of monitoring progress using the SASCI (Social Anxiety Session Change Index). From this point in therapy forward, at the beginning of each session, clients complete the SASCI.

Many individuals in treatment for social anxiety have some difficulty with casual conversations, even if it is not the primary focus of treatment. This chapter presents psychoeducational material about the importance of small talk in everyday life. The amount of in-session time spent will depend on how central this topic is to the specific client and how well the client is able to glean key points from the reading on their own. Two primary messages from this material are (a) casual conversations are the gateways to more significant relationships and (b) such conversations are, by definition, about inconsequential topics. Conversational situations are often the easiest exposures to design. They typically require few props, and a variety of circumstances can be easily staged. This chapter covers three typical automatic thoughts for conversations: not knowing what to say, not having anything interesting to say, and having poor conversational skills.

In this chapter, the therapist and client continue to refine their understanding of the client’s three components of anxiety and develop a Fear and Avoidance Hierarchy. A Fear and Avoidance Hierarchy is a “top 10” list of situations in which the client experiences social anxiety. The greatest fear is in the number 1 position. Once the items are generated, each is rated for the level of anxiety it evokes and the likelihood that the person would avoid the situation if it were to occur in his or her life. There are four steps in constructing a Fear and Avoidance Hierarchy: (a) brainstorming, (b) discovering what makes a situation easier or harder and refining the client’s list of situations, (c) making ratings of fear and avoidance for each situation, and (d) rank ordering the situations. A hierarchy is meant to provide a good representation of situations that cause the client anxiety.

Cognitive restructuring is a procedure that helps to examine how people are thinking and to consider whether there may be a more useful way to look at a situation that makes them anxious. Clients learn to identify the thinking errors in the automatic thoughts (ATs) they have when they get anxious. They also have the opportunity to see if they tend to use particular thinking errors when they have anxious thoughts. Clients are taught (a) what they think influences how anxious they feel and (b) how to change what they are thinking so that they can better manage their anxiety and do the things they want to do in life. This chapter introduces the idea of information-processing biases using the “amber-colored glasses” metaphor. As people learn to change their ATs, they feel less anxious and depressed.

Although everyone who experiences social anxiety fears being viewed negatively by others or performing poorly in social situations, the situations that evoke fears vary considerably from one person to the next. In this chapter, therapist and client continue to refine their understanding of the client’s three components of anxiety and develop a Fear and Avoidance Hierarchy, which is a rank-ordered list of situations in which a client experiences anxiety. There are four steps in constructing a Fear and Avoidance Hierarchy: (a) brainstorming, (b) discovering what makes a situation easier or harder and refining the client’s list of situations, (c) making ratings of fear and avoidance for each situation, and (d) rank ordering the situations. A hierarchy is meant to provide a good representation of situations that cause the client anxiety.

As individuals work through various exposures and associated cognitive restructuring, both therapist and client may notice that certain themes keep reoccurring. Themes in automatic thoughts reflect core beliefs that drive all of the difficulties a person is experiencing. These core beliefs may not come to mind easily; they are often associated with heightened affect, and the client may be more reluctant to discuss them. Once the client makes some significant improvement and completes at least three to four exposures, and when the therapist sees that cognitive restructuring frequently returns to a common theme, then it is time to present the material in this chapter.

This chapter introduces the next component of treatment—therapeutic exposure to feared situations (facing the situations that make someone anxious). Therapeutic exposure is a powerful technique that helps with the three components of social anxiety: behavioral, cognitive, and physiological. How exposure works and why it is such a crucial step in overcoming social anxiety are reviewed. The chapter presents the steps involved in completing a first in-session exposure, including picking the situation, doing the cognitive restructuring, setting an achievable behavioral goal, entering the situation, and processing what was learned from the exposure. The first in-session exposure is a highlight of this therapy.

The primary purpose of this chapter is to help the client understand his or her diagnosis in the context of normal and excessive social anxiety. Social anxiety is feeling tense, nervous, or frightened in situations that involve other people. The workbook describes a step-by-step therapy approach for overcoming social anxiety. The therapist will help the client gain an appreciation that cognitive–behavioral therapy (CBT) is effective and provide a basic understanding of the nature of CBT, including the investment of effort and energy required for the therapeutic alliance. The therapist will work to enhance motivation for change and build this therapeutic alliance.

This Therapist Guide presents information on the nature of social anxiety, empirically supported cognitive–behavioral techniques used to treat it, how to best implement these techniques, and how to deal with the problems that arise during treatment. The authors strive to offer a complete treatment that is informed by individual case conceptualization within an evidence-based practice framework. Socially anxious individuals commonly view anxiety as an all-or-nothing experience: Some people have excessive social anxiety, and others—healthy people—do not experience social anxiety. It is helpful for clients to begin to think of social anxiety on a continuum. In this treatment, collaborative empiricism is operationalized as an active therapist and active client working together to overcome social anxiety. The therapist brings expertise about social anxiety and cognitive–behavioral therapy. The client brings expertise about herself and the motivation to make changes in her life. For this treatment to be successful, the therapist must be comfortable with clients who may become extremely anxious.

The first in-session exposure is a highlight of this therapy. (It is specified that exposure must occur no later than session 8 of treatment.) This is the first opportunity to fully integrate all of the therapeutic elements. Everything up to this point has been preparation for facing feared situations. Prior to the session, the therapist is instructed to review the client’s Fear and Avoidance Hierarchy and to determine what situation will likely be role-played. For the first exposure, simple, straightforward scenarios that require little “pretending” are the best. Although it is easy to skip setting an achievable behavioral goal to save time, this step is essential. Debriefing the exposure is often the most powerful portion of the intervention.

Although women demonstrate higher levels of rumination than men, it is unknown whether instruments used to measure rumination have the same psychometric properties for women and men. To examine this question, we evaluated measurement invariance of the brooding and reflection subscales from the Ruminative Responses Scale (RRS) by gender, using data from four samples of undergraduates from three universities within the United States ( N = 4,205). A multigroup confirmatory factor analysis revealed evidence for configural, metric, and scalar invariance of the covariance structure of the 10-item version of the RRS. There were statistically significant latent mean differences between women and men, with women scoring significantly higher than men on both brooding and reflection. These findings suggest that the 10-item version of the RRS provides an assessment of rumination that is psychometrically equivalent across gender. Consequently, gender differences in brooding and reflection likely reflect valid differences between women and men.

We examined (1) differences between controls and patients with social anxiety disorder (SAD) in emotional clarity and attention to emotions; (2) changes in emotional clarity and attention to emotions associated with cognitive-behavioral group therapy (CBGT), mindfulness-based stress reduction (MBSR), or a waitlist (WL) condition; and (3) whether emotional clarity and attention to emotions moderated changes in social anxiety across treatment. Participants were healthy controls (n = 37) and patients with SAD (n = 108) who were assigned to CBGT, MBSR, or WL in a randomized controlled trial. At pretreatment, posttreatment, and 12-month follow-up, patients with SAD completed measures of social anxiety, emotional clarity, and attention to emotions. Controls completed measures at baseline only. At pretreatment, patients with SAD had lower levels of emotional clarity than controls. Emotional clarity increased significantly among patients receiving CBGT, and changes were maintained at 12-month follow-up. Emotional clarity at posttreatment did not differ between CBGT and MBSR or between MBSR and WL. Changes in emotional clarity predicted changes in social anxiety, but emotional clarity did not moderate treatment outcome. Analyses of attention to emotions were not significant. Implications for the role of emotional clarity in the treatment of SAD are discussed.