SOCIAL ANXIETY

BEHAVIORAL DEFINITIONS

1. Limited or no eye contact, coupled with a refusal or reticence to respond verbally to social overtures from others.
2. Excessive shrinking from or avoidance of contact with unfamiliar people for an extended period of time (i.e., six months or longer).
3. Social isolation and/or excessive involvement in isolated activities (e.g., reading, listening to music in his/her room, playing video games).
4. Extremely limited or no close friendships outside of the immediate family members.
5. Hypersensitivity to criticism, disapproval, or perceived signs of rejection from others.
6. Excessive need for reassurance of being liked by others before demonstrating a willingness to get involved with them.
7. Marked reluctance to engage in new activities or take personal risks because of the potential for embarrassment or humiliation.
8. Negative self-image as evidenced by frequent self-disparaging remarks, unfavorable comparisons to others, and a perception of self as being socially unattractive.
9. Lack of assertiveness because of a fear of being met with criticism, disapproval, or rejection.
10. Heightened physiological distress in social settings manifested by increased heart rate, profuse sweating, dry mouth, muscular tension, and trembling.

LONG-TERM GOALS

1. Eliminate anxiety, shyness, and timidity in social settings.
2. Initiate or respond to social contact with unfamiliar people or when placed in new social settings.
3. Interact socially with peers on a consistent basis without excessive fear or anxiety.
4. Achieve a healthy balance between time spent in solitary activity and social interaction with others.
5. Develop the essential social skills that will enhance the quality of interpersonal relationships.
6. Elevate self-esteem and feelings of security in interpersonal, peer, and adult relationships.
SHORT-TERM OBJECTIVES THERAPEUTIC INTERVENTIONS
1. Describe the history and nature of social fears and avoidance. (1, 2, 3) 1. Establish rapport with the client toward building a therapeutic alliance.
2. Assess the client's social anxiety and avoidance, including the focus of the fear, types of avoidance (e.g., distraction, escape, dependence on others), development of the fear, and the negative impact on daily functioning; consider using a structured interview (e.g., The Anxiety Disorders Interview Schedule—Parent Version or Child Version).
3. Assess the nature of any external stimulus, thoughts, or situations that precipitate the client's social fear and/or avoidance.
2. Complete psychological tests designed to assess the nature and severity of social anxiety and avoidance. (4) 4. Administer an objective measure of social anxiety to the client to further assess the depth and breadth of social fears and avoidance (e.g., Social Phobia and Anxiety Inventory for Children).
3. Disclose any history of substance use that may contribute to and complicate the treatment of social anxiety. (5) 5. Arrange for a substance abuse evaluation and refer the client for treatment if the evaluation recommends it.
4. Provide behavioral, emotional, and attitudinal information toward an assessment of specifiers relevant to a DSM diagnosis, the efficacy of treatment, and the nature of the therapy relationship.(6, 7, 8, 9, 10) 6. Assess the client's level of insight (syntonic versus dystonic) toward the “presenting problems” (e.g., demonstrates good insight into the problematic nature of the “described behavior,” agrees with others' concern, and is motivated to work on change; demonstrates ambivalence regarding the “problem described” and is reluctant to address the issue as a concern; or demonstrates resistance regarding acknowledgment of the “problem described,” is not concerned, and has no motivation to change).
7. Assess the client for evidence of research-based correlated disorders (e.g., oppositional defiant behavior with ADHD, depression secondary to an anxiety disorder), including vulnerability to suicide, if appropriate (e.g., increased suicide risk when comorbid depression is evident).
8. Assess for any issues of age, gender, or culture that could help explain the client's currently defined “problem behavior” and factors that could offer a better understanding of the client's behavior.
9. Assess for the severity of the level of impairment to the client's functioning to determine appropriate level of care (e.g., the behavior noted creates mild, moderate, severe, or very severe impairment in social, relational, vocational, or occupational endeavors); continuously assess this severity of impairment as well as the efficacy of treatment (e.g., the client no longer demonstrates severe impairment but the presenting problem now is causing mild or moderate impairment).
10. Assess the client's home, school, and community for pathogenic care (e.g., persistent disregard for the child's emotional needs or physical needs, repeated changes in primary caregivers, limited opportunities for stable attachments, persistent harsh punishment, or other grossly inept parenting).
image 5. Cooperate with an evaluation by a physician for psychotropic medication. (11, 12) 11. Arrange for the client to have an evaluation for a prescription of psychotropic medications.image
12. Monitor the client for prescription compliance, side effects, and overall effectiveness of the medication; consult with the prescribing physician at regular intervals.image
image 6. Participate in small group therapy for social anxiety, with or without parents, or individual therapy if the group is unavailable. (13) 13. Enroll the client, with parents if desired, in a small (closed enrollment) group for social anxiety or individual therapy if a group cannot be formed (see Cognitive-Behavioral Therapy for Social Phobia in Adolescents by Albano and DiBartolo; Social Effectiveness Therapy for Children and Adolescents by Beidel, Turner, and Morris); recommend reading to support client's progress (e.g., Stand Up, Speak Out Workbook by Albano and DiBartolo).image
7. Parents teach and reinforce healthy social skills and attitudes. (14) 14. Teach parents to model and reinforce positive and confident social skills to help the client become more comfortable socially (recommend Helping Your Anxious Child by Rapee et al.; Nurturing the Shy Child: Practical Help for Raising Confident and Socially Skilled Kids and Teens by Markway and Markway).
image 8. Verbalize an accurate understanding of social anxiety and the rationale for its treatment. (15, 16) 15. Convey a cognitive-behavioral model of social anxiety that supports the rationale for treatment (e.g., social anxiety derives from cognitive biases and leads to unnecessary avoidance that maintains the fear).image
16. Discuss how cognitive restructuring and exposure serve as an arena to desensitize learned fear, build social skills and confidence, and reality-test biased anxious thoughts and beliefs.image
image 9. Read recommended material that supports therapeutic goals toward increasing understanding of social anxiety and its treatment. (17) 17. Assign the client and/or parents to read psychoeducational material on social anxiety and its treatment (e.g., The Shyness and Social Anxiety Workbook by Antony and Swinson; Say Goodbye to Being Shy by Brozovich and Chase; Managing Social Anxiety—Workbook: A Cognitive-Behavioral Therapy Approach by Hope, Heimberg, and Turk; The Mindful Path Through Shyness by Flowers).image
image 10. Learn and implement calming and coping strategies to manage anxiety symptoms and focus attention usefully during moments of social anxiety. (18) 18. Teach the client relaxation (see New Directions in Progressive Relaxation Training by Bernstein, Borkovec, and Hazlett-Stevens) and attentional focusing skills (e.g., staying focused externally and on behavioral goals, muscle relaxation, evenly paced diaphragmatic breathing, ride the wave of anxiety) to manage social anxiety symptoms (recommend parents and child read The Relaxation and Stress Reduction Workbook for Kids by Shapiro and Sprague; Applied Relaxation Training [Audio Book CD] by Fanning and McKay).image
image 11. Identify, challenge, and replace fearful self-talk and beliefs with reality-based, positive self-talk and beliefs. (19, 20) 19. Explore the client's schema and self-talk that mediate his/her social fear response; challenge the biases; assist him/her in generating appraisals that correct for the biases and build confidence (recommend The Shyness and Social Anxiety Workbook by Antony and Swinson).image
20. Assign the client a homework exercise in which he/she identifies fearful self-talk and creates reality-based alternatives; review and reinforce success, providing corrective feedback for failure (or assign “Restoring Socialization Comfort” from the Adult Psychotherapy Homework Planner by Jongsma).image
image 12. Learn and implement social skills to reduce anxiety and build confidence in social interactions. (21) 21. Use instruction, modeling, and role-playing to build the client's general social and/or communication skills (see Social Effectiveness Therapy for Children and Adolescents by Beidel, Turner, and Morris; consider assigning “Observe Positive Social behaviors” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).image
image 13. Learn and implement social problem-solving skills for managing social stresses, solving daily problems, and resolving conflicts effectively. (22, 23, 24) 22. Teach the client tailored, age-appropriate social problem-solving skills, including calming skills (e.g., cognitive and somatic) and problem-solving skills (e.g., specifying problem, generating options, listing pros and cons of each option, selecting an option, implementing an option, and refining); encourage implementation in daily life and review for success (or assign “Progressive Muscle Relaxation” or “Problem-Solving Exercise” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).image
23. Teach the client conflict resolution skills (e.g., empathy, active listening, “I messages,” respectful communication, assertiveness without aggression, compromise), to prevent or manage social problems and improve personal and interpersonal functioning (supplement with “Becoming Assertive” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).image
24. Use behavioral skill-building techniques (e.g., modeling, role-playing, behavior rehearsal, and corrective feedback) to develop skills and work through several current conflicts.image
image 14. Gradually practice and improve new skills in various feared social situations. (25, 26, 27) 25. Direct and assist the client in construction of a hierarchy of anxiety-producing situations associated with social anxiety.image
26. Select initial in vivo or role-played exposures that have a high likelihood of being a successful experience for the client; do cognitive restructuring within and after the exposure, and use behavioral strategies (e.g., modeling, rehearsal, social reinforcement) to facilitate the exposure (see Social Effectiveness Therapy for Children and Adolescents by Beidel, Turner, and Morris).image
27. Assign the client a homework exercise in which he/she does an exposure exercise in a daily life situation and records responses; review and reinforce success, providing corrective feedback toward improvement (supplement with “Gradual Exposure to Fear” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).image
image 15. Increase participation in interpersonal or peer group activities. (28, 29) 28. Foster generalization and strengthening of new personal and interpersonal skills by encouraging the client to participate in extracurricular or positive peer-group activities (or assign “Greeting Peers” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis; also, The Shyness and Social Anxiety Workbook for Teens by Shannon).image
29. Build the client's one-to-one interactional skills by encouraging participation in a structured social activity such as inviting friends home or going to a school sporting event together (or assign “Developing Conversational Skills” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis); review toward building on successes and problem-solving obstacles.image
image 16. Increase participation in school-related activities. (30) 30. Consult with school officials about ways to increase the client's socialization (e.g., tutoring a more popular peer, pairing the client with popular peer on classroom assignments).image
image 17. Learn and implement strategies for building on gains made in therapy and preventing relapses. (31, 32, 33, 34) 31. Discuss with the client the distinction between a lapse and relapse, associating a lapse with an initial and reversible return of symptoms, fear, or urges to avoid and relapse with the decision to return to fearful and avoidant patterns.image
32. Identify and rehearse with the client the management of future situations or circumstances in which lapses could occur.image
33. Instruct the client to routinely use strategies learned in therapy (e.g., cognitive restructuring, social skills, exposure) while building social interactions and relationships.image
34. Develop a “coping card” or other record (e.g., MP3 recording) on which coping strategies and other important information (e.g., “Pace your breathing,” “Focus on the task at hand,” “You can manage it,” “It will go away”) are available for the client's later use.image
18. Family members learn skills that strengthen and support the client's positive behavior change. (35, 36, 37, 38) 35. Conduct sessions with parents or parents and client in which parents are taught how to prompt and reward courageous social behavior, empathetically ignore excessive complaining and other avoidant behaviors, manage their own anxieties, and model the behavior being taught in session.
36. Teach the family problem-solving and conflict resolution skills for managing problems among themselves and between them and the client.
37. Encourage the family to model constructive skills they have learned and to model and praise the therapeutic skills the client is learning (e.g., calming, cognitive restructuring, nonavoidance of unrealistic fears).
38. Conduct group Cognitive- Behavioral Therapy, including family members (see the FRIENDS series by Barrett et al.), in which the client learns anxiety management skills, and parents learn skills for managing the child's anxious behavior and for facilitating the client's progress (recommend Friends for Life Workbook for Youth by Barrett; Helping Your Anxious Child by Rapee et al.; Nurturing the Shy Child: Practical Help for Raising Confident and Socially Skilled Kids and Teens by Markway and Markway; The Shy Child: Helping Children Triumph Over Shyness by Swallow, to supplement treatment, if needed).
19. Identify strengths and interests that can be used to initiate social contacts and develop peer friendships. (39, 40) 39. Ask the client to list how he/she is like his/her peers; use this list to encourage contact with peers who share interests and abilities (supplement with “Greeting Peers” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).
40. Assist the client in identifying 5 to 10 of his/her strengths or interests and then instruct the client to utilize three strengths or interests in the upcoming week to initiate social contacts or develop peer friendships (or assign the “Show Your Strengths” exercise in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).
20. Learn to accept limitations in life and commit to tolerating, rather than avoiding, unpleasant emotions while accomplishing meaningful goals. (41) 41. Use an Acceptance and Commitment Therapy approach (see Acceptance and Mindfulness Treatments for Children and Adolescents by Greco and Hayes) to help the client accept uncomfortable realities such as lack of complete control, imperfections, and uncertainty and tolerate unpleasant emotions and thoughts while accomplishing value-consistent goals (supplement with The Mindful Path Through Shyness by Flowers and The Mindfulness and Acceptance Workbook for Anxiety by Forsyth and Eifert, if needed).
21. Verbalize how current social anxiety and insecurities are associated with past rejection experiences and criticism from significant others. (42, 43) 42. Explore for a history of rejection experiences, harsh criticism, abandonment, or trauma that fostered the client's low self-esteem and social anxiety.
43. Encourage and support the client in verbally expressing and clarifying feelings associated with past rejection experiences, harsh criticism, abandonment, or trauma.
22. Verbally describe the defense mechanisms used to avoid close relationships. (44) 44. Assist the client in identifying defense mechanisms (e.g., social withdrawal, being critical, exaggerating rejection, overreacting to mild criticism, etc.) that keep others at a distance and prevent him/her from developing trusting relationships; identify ways to minimize defensiveness.

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I: 300.23 Social Anxiety Disorder (Social Phobia)
300.02 Generalized Anxiety Disorder
309.21 Separation Anxiety Disorder
300.4 Dysthymic Disorder
296.xx Major Depressive Disorder
300.7 Body Dysmorphic Disorder
Axis II: V71.09 No Diagnosis

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM ICD-10-CM DSM-5 Disorder, Condition, or Problem
300.23 F40.10 Social Anxiety Disorder (Social Phobia)
300.02 F41.1 Generalized Anxiety Disorder
309.21 F93.0 Separation Anxiety Disorder
300.4 F34.1 Persistent Depressive Disorder
296.xx F32.x Major Depressive Disorder, Single Episode
296.xx F33.x Major Depressive Disorder, Recurrent Episode
300.7 F45.22 Body Dysmorphic Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-CM codes are associated with more than one ICD-10-CM and DSM-5 disorder, condition, or problem. In addition, some ICD-9-CM disorders have been discontinued, resulting in multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental Disorders (2013) for details.

 

 

image indicates that the Objective/Intervention is consistent with those found in evidence-based treatments.