Social Phobia 383
restructuring over exposure alone will produce misleading results because it is very dif-
ficult to ensure external validity of the treatment conditions. They concluded that “both
cognitive restructuring and exposure should be considered fundamental and essential
aspects of CBT for social anxiety disorder and that they are best considered as interre-
lated techniques designed to do the same thing: allow the client to experience what the
situation is actually like, as opposed to how they fear or think it will be” (Rodebaugh
et al., 2004, pp. 890–891). We believe practitioners and clinical researchers alike would
be well advised to heed this recommendation before concluding that one interrelated
therapeutic ingredient is more effective than another.
Clinician Guideline 9.23
Cognitive therapy that includes both cognitive restructuring and systematic exposure to
social anxiety situations produces clinically significant effects for three- quarters of indi-
viduals with specific or generalized social phobia. Moreover, cognitive therapy may pro-
duce more enduring benefits for social phobia than pharmacotherapy alone, although more
research is needed to establish this finding.summary anD ConClusionSocial phobia is a marked and persistent apprehension and nervousness about social sit-
uations due to an exaggerated fear of negative evaluation by others. It is unique among
the anxiety disorders in its self- defeating effects. The occurrence of intense social anxi-
ety is associated with involuntary inhibitory behaviors that interfere in social perfor-
mance, thereby conferring some of the very effects most feared by the individual. The
disorder fits most closely to a dimensional conceptualization with milder, more circum-
scribed forms of social anxiety at one end, more severe generalized social phobia at the
upper end, and avoidant personality disorder at the extreme end of severity.
A reformulated cognitive model of social phobia was presented (see Figure 9.1) in
which anticipated or actual exposure to anxiety- provoking situations activates endur-
ing maladaptive self- referent social schemas that cause an automatic attentional bias for
schema- congruent social threat stimuli and an explicit interpretative bias in which the
probability and severity that others have formed a negative impression of the socially
anxious person is exaggerated. In addition excessive self- focused attention on an internal
anxious state is taken as strong confirmatory evidence that they are viewed by others as
weak and ineffective. Socially anxious individuals exhibit involuntary inhibitory behav-
ior when around others and engage in various safety behaviors to conceal their anxiety
and perceived ineffectiveness. However, these strategies tend to exacerbate anxiety and
individuals’ negative evaluation of their social performance. They leave the situation
feeling embarrassed and humiliated, with postevent recall of past social experiences
biased for retrieving evidence of social threat and personal failure. Empirical evidence
that social phobia is characterized by an explicit social threat interpretation bias, a mal-
adaptive social self- schema organization, an automatic attentional bias for social threat
cues, a heightened self- focused attention on interoceptive cues, and excessive postevent
rumination supports key elements of the cognitive model.