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Chapter 9
Cognitive Therapy of Social Phobia
Nothing so much prevents our being natural
as the desire to seem so.
—Fr a n ç o i s, du c d e La ro c h eF o u c a uL d
(French writer and aristocrat, 1613–1680)Gerald is a 36-year-old man who has worked as an accountant for a large
multinational trucking firm for the past 12 years and who has a long history of
severe social anxiety. SCID assessment revealed that he met DSM-IV diagnos-
tic criteria for generalized social phobia. He reported intense anxiety in most
social situations with an overwhelming fear that other people will notice him.
His main concern was that they would notice that he was hot and flushed and
would think “What’s wrong with him?”, “He doesn’t look normal,” and “He
must have low self- esteem or some serious mental problem.” Gerald believed
that people “could look right through him” and so he was always hypervigilant
when around others. He was also concerned that others would think he was
boring and wasting their time. Gerald noted that he is almost always anxious
when around other people and recognized that his anxiety is excessive. Over
the years he got to the point where he avoids social contact as much as possible,
spending most of his time outside of work alone and isolated. He has never
had an intimate relationship and no close friends. He prefers to avoid people
because of the anxiety and a fear that social interaction will result in obliga-
tions to others even though he realizes the avoidance has been detrimental to
his career. A year ago he joined a health club for a few months but found it too
anxiety- provoking to attend. Gerald rated participating in meetings, taking a
course, meeting an unfamiliar person, answering the telephone, taking public
transportation, or even visiting an acquaintance as very anxiety- provoking.
Gerald indicated that he has been socially anxious since childhood and that
it has severely limited his life. In fact the anxiety and self- imposed loneliness
have been so great that he commented “I’m tired of waiting for life to start;
sometimes I just want to get it over with.”
Gerald’s clinical presentation is fairly typical of someone with a chronic
and severe generalized social phobia. In fact he met criteria for an Axis II
avoidant personality disorder as indicated by (1) his attempt to avoid signifi-