Concept of Social Anxiety Disorder (SAD)

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Social anxiety disorder (SAD) is an extreme fear of embarrassment or humiliation in human society or performing a work or role in situations and is usually described by avoidance of these situations. The fear is usually connected with marked anxiety and deterioration in several areas, including work, social life, and family life (Herbert, 2005).

According to Kessler et al, (2005) SAD is the fourth most common psychiatric disorder in the United States after major depression, alcohol dependence, and specific phobia, with a lifetime prevalence rate of12.1% and onset often before age 18 (Judd, 1994).

Social anxiety disorder (social phobia) is distinguished naturally by a fear of unpleasant reaction in social settings that may be accompanied by blushing, trembling and cognitive problems (Fahlen, 1996). In addition, fear anxiety situations may develop a factor leading to limitation of daily activities. Social anxiety disorder also highly co-exists with affective disorders, other anxiety disorders and substance abuse (Judd, 1994).

Social anxiety disorder may be grouped into two subtypes: generalized and specific. van der Linden et al., 2000 explain that the generalized form involves anxiety in a variety of social situations, considering that the specific type is associated with anxiety in one or two social settings. Besides, the generalized form of social phobia tends to produce more distress than does the specific subtype (van der Linden et al., 2000).


Cognitive-behavioral group therapy or CBGT is the most widely studied treatment program for SAD (Heimberg, 2002). It stressed the cognitive factors that maintain SAD (e.g., abnormally increase negative beliefs about one’s performance in social situations), as well as behavioral factors (e.g., avoidance of these situations).

CBGT aimed that this maintaining factors by means of mental change in an effort to reduce/lessen negative beliefs, as well as with in life and to have exposure exercises to decrease avoidance and test dysfunctional beliefs. Several studies support the effectiveness of CBGT and it is added on the list of experiences supported treatments developed by the American Psychological Association’s Committee on Science and Practice (Chambless et al., 1996).

Even though conventional CBT for SAD has been shown to be effective, most individuals continue to display continuing symptoms and impairment after treatment, and a indicative advantage do not respond to treatment at all (Herbert et al.,2005).

Few studies have examined the effect of traditional CBT on quality of life in SAD, but in study by Eng et al, (2001) found that, although quality of life had improved by post treatment, scores still did not approach those of nonanxious persons.

A 2005 research found that with only about 12 weeks of CBT could improve the interpersonal attitude although other expectations may not be present (Eng et al, 2001). It was then suggested that improving or modifying the process may provide better results to having improved quality of life.

There are other medications used in treatment of social anxiety disorder. Monoamine oxidase inhibitor has been cautiously used due to adverse effects. Blanco et al (2002) suggested that benzodiazepines such as clonazepam used in social anxiety disorder may be abused (van der Linden et al., 2000).

On the other hand, Van der Linden et al (2000) cited that the use of Beta adrenergic blocking agents could be useful only with some specific social anxiety disorder. One which is considered more popular in use is selective serotonin reuptake inhibitors considered one of the safest and most effective (Blanco et al, 2003). It is also effective for social phobia.

Hayes (1999) had earlier suggested combining standard exposure-based treatment with acceptance and commitment therapy or ACT. The treatment model suggests that psychopathology was caused mainly by the “fusion” of distressing thoughts and feelings with the desire to control or get away with that kind of experience as against the frequency of the experience.

Hayes (1999) has called this struggle to remove or limit the experience as “experiential avoidance”. ACT aims to prepare the patient to learn how to experience fully and with clearer understanding in order to align with other personal desires (Herbert, 2002).

ACT does not attempt to reduce SAD symptoms but it may be expected once patient has fully adapted to the program. System-wise, ACT has adapted some techniques from CBT incorporating it with humanistic and experiential models with more leeway to adaptations.

It was observed that ACT techniques focus on mindful comprehension and understanding of thoughts as it process experiences. In this instance, mindfulness may mean openness to actions and consequences as well as being aware of what is going on surrounding the patient Kabat-Zinn (1990).

This technique has been caught up in recently improved CBT approaches including the dialectical behavior therapy (Linehan, 1991). Teasedale et al (2000) also noted that ACT was incorporated in mindfulness-based cognitive therapy to prevent relapse in major depressive disorder.

With the recent shown potential of ACT, it has been considered as a viable option for SAD. It was proposed that ACT could increase and develop the patient functioning and quality of life in bigger areas previously limited with traditional CBT. In addition, considering the condition of SAD patients akin to engage in exposure-based treatments, ACT is an alternative that actually prepare them and made them accept of their fear (Barlow, 1994).


Under the ACT technique, several concepts are presented in treatment. The first is called “creative hopelessness conducted in Sessions 1 and 2. In this level, the patient is assisted in appreciating the futility of previous acts to limit their social anxiety. The next level or Session 3 exposes the patient to willingly accept unwanted private experiences.

They are programmed to entertain unwanted thoughts and feeling as they engage in goal directed behavior such as socializing in groups or having conversation.

This is usually done from Session 3 until Session 12 although each level is modified to increase impact on the participant or patient. There is focus on programming the patient to accept practice willingness to experience anxiety while under social activities and that each session, anxiety or fear is increased until the last level.

The next level has the participants engage in mindfulness and additional techniques and usually introduced at Session 4. This portion has the participants facilitate non-judgmental awareness of unwanted thoughts and feelings.

They are encouraged to accept in willingly and emphasized that analysis or modification is not necessary. The exercise attempts to separate the self from thoughts or internal experiences, called by Hayes (1999) as “”cognitive defusion.” Values and aims of the program are thoroughly and repeatedly discussed throughout, but at Session 7, the participants are made to explicitly clarify their values.

They also facilitate valued actions, specifically, developing more meaningful social relations even if they find challenges in the process. The key concepts are said to be explained through metaphors and other experiential activities as has been introduced by Hayes et al (1999).

Starting at the third session, standard behavior therapies for SAD patients are undergone. These may include but not limited to role-playing with fellow participants, actual exposure exercises which are given a assignment, and other social skills development included in the process (Herbert et al, 2005) Every session has the participants engage in brief review, suggestions for activities, practice and assigned tasks at the end.


Symptom reduction is the indirect goal of ACT, integrating both novel and existing therapy techniques for SAD patients. It has been noted that ACT is one of the better alternatives to address SAD as there is the step-by-step process of exposing and opening the acceptance of patients about the inevitable invasion of negativity not only in reality but also with human thoughts based on experiences or even fear and imagination.

Unwanted thoughts, fears and anxiety are introduced to patients as part and parcel of life, of their personality, and that patients are made aware of their being in union with their fellow as each has its own fears, negative thoughts and min-invasive experiences. As CBT provided a basis for developing programs to address SAD, ACT has provided a novel way to address this problem that has been seen and observed as a more viable alternative therapy.


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