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Social Anxiety Disorder (Advances in Psychotherapy


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Table of Contents

Preface * Dedication; 1 Description; 1.1 Terminology; 1.2 Definition; 1.3 Epidemiology; 1.4 Course and Prognosis; 1.5 Differential Diagnosis: Panic Disorder with Agoraphobia * Generalized Anxiety Disorder * Specific Phobia * Depression * Avoidant Personality Disorder * Schizoid Personality Disorder; 1.6 Comorbidity; 1.7 Diagnostic Procedures and Documentation: Interviewer Administered Measures * Self-Report Severity Measures * Behavioral Approach Tests (BATs) * Assessing Suitability for Treatment; 2 Psychological Approaches to Understanding Social Anxiety Disorder; 2.1 Clark and Wells' Cognitive Model; 2.2 Rapee and Heimberg's Cognitive Behavioral Model; 2.3 Negative Learning Experiences and Social Anxiety; 2.4 Temperamental Bases of Social Anxiety Disorder; 2.5 Implications for Treatment; 3 Diagnosis and Treatment Indications; 3.1 Key Features to be Assessed: Situational Triggers * Physical Features * Cognitive Features * Avoidance Strategies * Safety Behaviors * Anxiety Sensitivity * Social Skills * Environmental Factors * Comorbidity * Functional Impairment; 3.2 Overview of Effective Treatment Strategies; 3.3 Factors That Influence Treatment Decisions: Age, Sex, and Ethnicity * Education * Family and Relationship Factors * Client Preference * Treatment History * Ability to Articulate Cognitions * Anxiety Sensitivity and Fear of Sensations * Severity of Avoidance and Safety Behaviors * Social Skills * Comorbidity * Group vs. Individual Treatment; 4 Treatment; 4.1 Methods of CBT: Self-Monitoring * Psychoeducation * Cognitive Strategies * Exposure-Based Strategies * Social Skills Training * Relaxation and Arousal Management Strategies; 4.2 Mechanisms of Action: Cognitive Models * Behavioral Models * Emotional Processing Models; 4.3 Efficacy: Efficacy of CBT * Predictors of Outcome * Preventing Relapse and Return of Symptoms; 4.4 Combination Treatments: Medication Treatments * Comparing and Combining Medications and CBT; 4.5 Overcoming Barriers to Treatment: Treatment Ambivalence * Homework Noncompliance * Adapting Treatment for Comorbidity; 4.6 Adapting Treatment for Different Age Groups; 4.7 Adapting Treatment for Different Cultures; 5 Case Vignettes; 6 Further Reading; 7 References; 8 Appendix: Tools and Resources.


"Martin Antony and Karen Rowa are to be congratulated for putting together a concise, practical, eminently readable primer on diagnosis and treatment of social anxiety disorder. Yes, the advice is evidence-based, but it is also grounded in years of experience treating patients with social anxiety disorder. It is required reading for any therapist seeking to broaden or sharpen their expertise in this area." Murray B. Stein, MD, MPH, Professor, Department of Psychiatry, Department of Family and Preventive Medicine, Director, Anxiety & Traumatic Stress Disorders Program, University of California San Diego, CA "This book fills an important gap in the literature - filled with clinical examples and advice, its straight-forward presentation will allow clinicians with various levels of expertise to implement these efficacious interventions. Antony and Rowa provide not only a valuable tool for their colleagues but also hope for the millions who suffer from social anxiety disorder." Deborah C. Beidel, PhD, Professor and Director of Clinical Training, University of Central Florida, Orlando, FL "This volume is a well-organized, reader-friendly guide to social anxiety disorder. In addition to providing key information about this condition, Antony and Rowa describe a variety of cognitive-behavioral treatment approaches, and present an authoritative summary of the empirical data that support their effectiveness. Clinicians will find the case vignettes and strategies for handling treatment problems to be particularly helpful. As a guide to clinical practice, this book has much to recommend it." Lynn Alden, PhD, Professor, Department of Psychology, University of British Columbia, Vancouver, BC"Social anxiety disorder (SAD), formerly known as social phobia, wasofficially recognized as a distinct clinical entity only with the publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980). Very little was known back then about this highly prevalent and debilitating disorder. The lack of research on this topic prompted Liebowitz, Gorman, Fyer, and Klein (1985) to publish an article with the title A"Social Phobia: Review of a Neglected Anxiety Disorder.A" Since then, the number of books, scientific publications, and treatment studies on SAD has been increasing exponentially from year to year. It is difficult to say what the reason for this growing interest in SAD is-perhaps it has to do with the high prevalence rate; SAD is one of the most common mental disorders in the population (Kessler, Berglund, Demler, Jin, & Walters, 2005). Perhaps it has to do with the approval of paroxetine (Paxil) by the Food and Drug Administration for the treatment of SAD and the effective advertisement campaign to raise awareness of the problem and to promote the drug; or perhaps it has to do with the encouraging results from psychotherapy research studies demonstrating the efficacy of cognitive-behavioral treatments (CBT) for the disorder. Whatever the reason, characterizing this condition as a A"neglected anxiety disorderA" is clearly no longer appropriate. In fact, SAD has become one of the most studied disorders. Antony and Rowa's text gives the reader a glimpse into the enormous wealth of knowledge that has been accumulated on the psychopathology and treatment of SAD. Social Anxiety Disorder is part of a new series titled Advances inPsychotherapy-Evidence-Based Practice with Danny Wedding as theseries editor. This series has been developed with the support of theSociety of Clinical Psychology (Division 12) of the American Psychological Association with the goal to develop continuing education courses for home study. The targeted audience of this series includes therapists who are looking for practical, evidence-based information on the diagnosis and treatment of the most common disorders. It provides practical and user-friendly guidelines for professionals in their daily work. Moreover, it serves as an educational resource for students and for practice-orientedcontinuing education. Martin Antony, one of the authors of this book, is well known in the field of anxiety disorders. He has written extensively on this topic and is particularly skilled at translating contemporary research studies into consumer-friendly therapist manuals and patient self-help books. His coauthor, Karen Rowa, is also an experienced author of self-help books and treatment manuals. Clearly, Antony and Rowa are the right people for the job. When browsing through this thin book, the reader will notice the short paragraphs, frequent and simple tables (there are 15 in total), bulleted text at various places to summarize or highlight certain material, and bolded notes in the margins that summarize and emphasize certain information. With only 93 pages, the text is very succinct. It is divided into short chapters that include a general description of social anxiety (Chapter 1), psychological treatment (CBT) models (Chapter 2), treatment-relevant issues (Chapter 3), a more indepthdescription of Heimberg's CBT protocol (Chapter 4), and twotypical case vignettes (Chapter 5). The appendix further includes anumber of useful therapy tools, including a list of professional andconsumer resources, commonly used handouts for treatment, and acommon and brief self-report questionnaire to assess the severity ofSAD. This format makes the text a useful tool for any clinician whorequires basic information on SAD. Despite the brevity of the text, the book covers a broad area, ranging from basic psychopathology to pharmacotherapy and, of course, CBT. As a result of its brevity and breadth, some of the information remains relatively superficial and cursory. Furthermore, the nature and expression of SAD are primarily described by what it is not (e.g., panic disorder, specific phobia, generalized anxiety disorder, specific phobia depression, Axis II psychopathology). This leaves open (or even raises) many questions about the nature and expression of SAD. For example,the description of SAD is limited to the DSM and does not explore other dimensions that might be relevant for treatment, such as selfconsciousness, shyness, and anger (Hofmann, Heinrichs, & Moscovitch, 2004). Similarly, the CBT models are covered in only one 8-page chapter. This chapter examines only the decade-old models by Clark and Wells (1995) and Rapee and Heimberg (1997). A lot of research has been conducted within the last 10 years, and the treatment models for SAD have become considerably more sophisticated (Clark, 2001; Hofmann, 2007a), leading to more improved treatment techniques (Hofmann & Otto, 2008). For example, videotaped feedback exposures, attentionretraining exercises, safety behavior targeting, and social mishap exposure techniques appear to be particularly efficacious and are emphasized in contemporary CBT models (Hofmann, 2007a), whereas social skills training and role play exercises are significantly less emphasized in modern psychological treatment protocols for SAD. The review of the combination treatment of CBT and pharmacotherapy, on the other hand, is very thorough and up to date.Particularly hopeful, in my view, is the use of cognitive enhancers asadjunctive treatments to CBT (Guastella et al., 2008; Hofmann, 2007b).In sum, the text by Antony and Rowa provides a useful guide forclinicians to gain basic information on the nature and treatment of SAD. However, I suggest that supplementary information should be usedwhen conducting treatments with individuals with SAD. Despite some ofthe weaknesses, the text is an excellent addition to the library of any clinician and trainee.PsycCRITIQUES, Vol. 53, issue 30, 2008, American Psychological Association, reviewed by Stefan G. Hofmann

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